1
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Răducan-Florea IV, Leaşu FG, Dinu EA, Rogozea LM. The Nocebo Effect: A Bias in Clinical Practice-An Ethical Approach. Am J Ther 2024:00045391-990000000-00183. [PMID: 38557480 DOI: 10.1097/mjt.0000000000001730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
BACKGROUND The nocebo effect is often disregarded in medical practice and is certainly much less known than the placebo effect, although, in reality, both can influence therapeutic decision making and the quality of life of patients. However, the nocebo effect raises a number of issues not only of a practical nature related to clinical activity but also ethical dilemmas related to the observance of the patient's autonomy, nonmaleficence, or informed consent and the information on which it is based. AREAS OF UNCERTAINTY The ethical dilemmas raised by the nocebo effect revolve around how informed consent can be achieved, the accuracy and volume of information that is transmitted to the patient, and how to report negative side effects of therapeutic treatment. DATA SOURCES In September 2023, a narrative analysis of the literature was conducted using a combination of keywords such as nocebo, placebo, ethics, therapeutic relationship from PubMed, Scopus, Google Scholar, and so on, as well as from official documents developed at an international level (World Health Organization), for a period of 10 years (2012-2021). RESULTS Analyzing the articles that remarked upon the significant impact of ethics in nocebo research or in the therapeutic relationship, we can state that the existence of several relevant issues of interest have been detected regarding the ethical use of nocebo and its impact in research or in clinics and thus the need for proper knowledge and management of the impact of nocebo effects. The ethical paradox of obtaining informed consent with the 2 goals, first, the need for complete information and second, the preservation of the autonomy of the patient, respectively, that of "primum non-nocere" and of avoiding unnecessary harm by revealing probable adverse effects is a point of interest for numerous studies. The potential for a nocebo effect is present when we inform patients about the risks and benefits of treatment, there being a clear link between the moral and ethical duty to inform patients and the need to avoid situations that increase the nocebo impact on how the disease or the adverse effects of the treatment are perceived. Adapting information about the side effects of medicines should focus on ensuring a balance between transparency and caution, especially in patients with a high potential for nocebo effect. CONCLUSIONS The nocebo effect had for a long time been unknown or denied, although it can interfere with the results of the treatment used. As the nocebo phenomenon becomes increasingly known in medical practice, the clinical and ethical implications are identified by medical staff, and nocebo's adverse responses are no longer ignored.
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Affiliation(s)
| | - Florin G Leaşu
- Basic, Preventive and Clinical Sciences Department, Transilvania University, Brasov, Romania
| | - Eleonora A Dinu
- Basic, Preventive and Clinical Sciences Department, Transilvania University, Brasov, Romania
| | - Liliana M Rogozea
- Basic, Preventive and Clinical Sciences Department, Transilvania University, Brasov, Romania
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2
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Clayton A. "On Suggestion" by John Bostock, 1923: A comparison with twenty-first century understandings of the placebo effect. Australas Psychiatry 2023; 31:761-763. [PMID: 37402389 PMCID: PMC10725613 DOI: 10.1177/10398562231187982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/06/2023]
Abstract
OBJECTIVES This paper describes Australian psychiatrist John Bostock's 1923 concept of suggestion and compares it to our understandings, in 2023, of the placebo effect. CONCLUSIONS Bostock's 1923 article on "suggestion" gives us a glimpse of the history of Australian psychiatry. It also stimulates thought about the current understandings of the placebo effect. Now, as then, placebo effects can play a critical role in patient outcomes. However, careful consideration is required to ensure contemporary ethical standards are met and harm is not done.
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Affiliation(s)
- Alison Clayton
- School of Historical and Philosophical Studies, University of Melbourne, Melbourne, Australia
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3
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Defelippe VM, J M W van Thiel G, Otte WM, Schutgens REG, Stunnenberg B, Cross HJ, O'Callaghan F, De Giorgis V, Jansen FE, Perucca E, Brilstra EH, Braun KPJ. Toward responsible clinical n-of-1 strategies for rare diseases. Drug Discov Today 2023; 28:103688. [PMID: 37356616 DOI: 10.1016/j.drudis.2023.103688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 06/08/2023] [Accepted: 06/20/2023] [Indexed: 06/27/2023]
Abstract
N-of-1 strategies can provide high-quality evidence of treatment efficacy at the individual level and optimize evidence-based selection of off-label treatments for patients with rare diseases. Given their design characteristics, n-of-1 strategies are considered to lay at the intersection between medical research and clinical care. Therefore, whether n-of-1 strategies should be governed by research or care regulations remains a debated issue. Here, we delineate differences between medical research and optimized clinical care, and distinguish the regulations which apply to either. We also set standards for responsible optimized clinical n-of-1 strategies with (off-label) treatments for rare diseases. Implementing clinical n-of-1 strategies as defined here could aid in optimized treatment selection for such diseases.
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Affiliation(s)
- Victoria M Defelippe
- Department of Child Neurology, UMCU Brain Center, University Medical Center Utrecht, Universiteitsweg 100, 3584 CG Utrecht, the Netherlands; European Reference Network for Rare and Complex Epilepsies (EpiCare), Department of Paediatric Clinical Epileptology, Sleep Disorders and Functional Neurology, c/o Pr Arzimanoglou, Hôpital Femme Mère Enfant, 59 Boulevard Pinel, 69677 Bron, France.
| | - Ghislaine J M W van Thiel
- Department of Medical Humanities, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Universiteitsweg 100, 3584 CG Utrecht, the Netherlands
| | - Willem M Otte
- Department of Child Neurology, UMCU Brain Center, University Medical Center Utrecht, Universiteitsweg 100, 3584 CG Utrecht, the Netherlands
| | - Roger E G Schutgens
- Van Creveldkliniek, Benign Hematology Center, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands; European Reference Network for Oncological and non-oncological Rare Hematological Diseases (EuroBloodNet), Hôpital St Louis / Université Paris 7, 1 Avenue Claude Vellefaux, 75475 Paris, France
| | - Bas Stunnenberg
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Donders Center for Medical Neuroscience, Radboud University Medical Center, Thomas van Aquinostraat 4, 6525 GD Nijmegen, the Netherlands
| | - Helen J Cross
- European Reference Network for Rare and Complex Epilepsies (EpiCare), Department of Paediatric Clinical Epileptology, Sleep Disorders and Functional Neurology, c/o Pr Arzimanoglou, Hôpital Femme Mère Enfant, 59 Boulevard Pinel, 69677 Bron, France; University College London (UCL) Great Ormond Street, Institute of Child Health, 30 Guilford Street, London WC1N 1EH, UK
| | - Finbar O'Callaghan
- European Reference Network for Rare and Complex Epilepsies (EpiCare), Department of Paediatric Clinical Epileptology, Sleep Disorders and Functional Neurology, c/o Pr Arzimanoglou, Hôpital Femme Mère Enfant, 59 Boulevard Pinel, 69677 Bron, France; Paediatric Neuroscience, UCL Great Ormond Street, Institute of Child Health, 30 Guilford Street, London WC1N 1EH, UK
| | - Valentina De Giorgis
- European Reference Network for Rare and Complex Epilepsies (EpiCare), Department of Paediatric Clinical Epileptology, Sleep Disorders and Functional Neurology, c/o Pr Arzimanoglou, Hôpital Femme Mère Enfant, 59 Boulevard Pinel, 69677 Bron, France; Fondazione Mondino National Institute of Neurology, University of Pavia, Via Mondino 2, 27100 Pavia, Italy
| | - Floor E Jansen
- Department of Child Neurology, UMCU Brain Center, University Medical Center Utrecht, Universiteitsweg 100, 3584 CG Utrecht, the Netherlands; European Reference Network for Rare and Complex Epilepsies (EpiCare), Department of Paediatric Clinical Epileptology, Sleep Disorders and Functional Neurology, c/o Pr Arzimanoglou, Hôpital Femme Mère Enfant, 59 Boulevard Pinel, 69677 Bron, France
| | - Emilio Perucca
- European Reference Network for Rare and Complex Epilepsies (EpiCare), Department of Paediatric Clinical Epileptology, Sleep Disorders and Functional Neurology, c/o Pr Arzimanoglou, Hôpital Femme Mère Enfant, 59 Boulevard Pinel, 69677 Bron, France; Department of Medicine, University of Melbourne (Austin Health), Heidelberg, VIC 3084, Australia; Department of Neuroscience, Monash University, Melbourne, VIC, Australia
| | - Eva H Brilstra
- European Reference Network for Rare and Complex Epilepsies (EpiCare), Department of Paediatric Clinical Epileptology, Sleep Disorders and Functional Neurology, c/o Pr Arzimanoglou, Hôpital Femme Mère Enfant, 59 Boulevard Pinel, 69677 Bron, France; Department of Genetics, Center for Molecular Medicine, University Medical Center Utrecht, Universiteitsweg 100, 3584 CG Utrecht, the Netherlands
| | - Kees P J Braun
- European Reference Network for Rare and Complex Epilepsies (EpiCare), Department of Paediatric Clinical Epileptology, Sleep Disorders and Functional Neurology, c/o Pr Arzimanoglou, Hôpital Femme Mère Enfant, 59 Boulevard Pinel, 69677 Bron, France; Department of Child Neurology, UMCU Brain Center, University Medical Center Utrecht, Universiteitsweg 100, 3584 CG Utrecht, the Netherlands
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4
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Arrow K, Burgoyne LL, Cyna AM. Implications of nocebo in anaesthesia care. Anaesthesia 2022; 77 Suppl 1:11-20. [DOI: 10.1111/anae.15601] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/18/2021] [Indexed: 12/20/2022]
Affiliation(s)
- K. Arrow
- Women’s and Children’s Hospital North Adelaide SA Australia
| | - L. L. Burgoyne
- Women’s and Children’s Hospital North Adelaide SA Australia
| | - A. M. Cyna
- Women’s and Children’s Hospital North Adelaide SA Australia
- Discipline of Acute Care Medicine University of Adelaide Adelaide SA Australia
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5
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Rodrigues BA, Silva LMCP, Lucena HÍDS, Morais EPGD, Rocha AC, Alves GADS, Benevides SD. Nocebo effect in health communication: how to minimize it? REVISTA CEFAC 2022. [DOI: 10.1590/1982-0216/20222443022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
ABSTRACT Purpose: to describe the strategies used to minimize the nocebo effect in health communication. Methods: an integrative review of the literature. The keywords “nocebo effect” and “health communication” and their combinations were used in English, Portuguese, and Spanish to search publications from 2011 to 2021 in MEDLINE, Latin American and Caribbean Health Sciences Literature (LILACS), Cochrane Library, EMBASE, and Web of Science/ISI. The following research question was used: “Which strategies have been used to minimize the nocebo effect in health communication?”. Literature Review: altogether, 77 articles were found, although only six met the inclusion criteria and comprised the review sample. Their year of publication ranged from 2015 to 2021. Positive framing, assertive communication, and contextual factors were the strategies used to minimize the nocebo effect. Conclusion: the strategies used to minimize the nocebo effect were contextual factors, motivational talk, positive framing, assertive communication, and empathetic communication. These communication techniques are seemingly effective, though still little known by health professionals. This knowledge is important as it helps develop communicative skills aiming at humanized patient care.
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6
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Rodrigues BA, Silva LMCP, Lucena HÍDS, Morais EPGD, Rocha AC, Alves GADS, Benevides SD. Efeito nocebo na comunicação em saúde: como minimizá-lo? REVISTA CEFAC 2022. [DOI: 10.1590/1982-0216/20222443022s] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
RESUMO Objetivo: descrever as estratégias para minimizar o efeito nocebo na comunicação em saúde. Métodos: trata-se de uma revisão integrativa da literatura. Os descritores utilizados foram: “Efeito nocebo” e “comunicação em saúde”, em inglês, português e espanhol e suas combinações, no período de 2011 a 2021, nas bases de dados da Medline, Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS), Cochrane Library, Embase e Web of Science/ISI. A pergunta de investigação para esse estudo foi: Quais as estratégias utilizadas para minimizar o efeito nocebo na comunicação em saúde? Revisão da Literatura: foram encontrados 77 artigos. Apenas seis preencheram os critérios de inclusão e compuseram a amostra da revisão. Os anos de publicação dos artigos variaram entre 2015 e 2021. As estratégias definidas para minimizar o efeito nocebo foram: enquadramento positivo, comunicação assertiva e utilização de fatores contextuais. Conclusão: as estratégias encontradas para minimizar o efeito nocebo foram fatores contextuais, conversa motivacional, enquadramento positivo, comunicação assertiva e comunicação empática. Essas técnicas de comunicação parecem ser efetivas, mas ainda são pouco conhecidas pelos profissionais em saúde. Esse conhecimento se faz importante, pois auxilia no desenvolvimento de habilidades comunicativas que visam à humanização do cuidado ao paciente.
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7
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Carmona L. More, none, less therapeutic effect? Should we start talking about a 'lessebo' effect? Rheumatology (Oxford) 2021; 61:486-487. [PMID: 34605912 DOI: 10.1093/rheumatology/keab747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 09/24/2021] [Indexed: 11/14/2022] Open
Affiliation(s)
- Loreto Carmona
- Instituto de Salud Musculoesquelética (Inmusc), Madrid, Spain
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8
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Arnold MH, Komesaroff P, Kerridge I. Understanding the ethical implications of the rituals of medicine. Intern Med J 2020; 50:1123-1131. [PMID: 32929818 DOI: 10.1111/imj.14990] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 07/01/2020] [Accepted: 07/03/2020] [Indexed: 11/27/2022]
Abstract
Rituals may be understood broadly as stereotyped behaviours carrying symbolic meanings, which play a crucial role in defining relationships, legitimating authority, giving meaning to certain life events and stabilising social structures. Despite intense interest in the subject, and an extensive literature, relatively little attention has been given to the nature, role and function of ritual in contemporary medicine. Medicine is replete with ritualistic behaviours and imperatives, which play a crucial role in all aspects of clinical practice. Rituals play multiple, complex functions in clinical interactions and have an important role in shaping interactions, experiences and outcomes. Longstanding medical rituals have been disrupted in the wake of coronavirus disease 2019 (COVID-19). Medical rituals may be evident or invisible, often overlap with or operate alongside instrumentalised practices, and play crucial roles in establishing, maintaining and guaranteeing the efficacy of clinical practices. Rituals can also inhibit progress and change, by enforcing arbitrary authority. Physicians should consider when they are undertaking a ritual practice and recognise when the exigencies of contemporary practice are affecting that ritual with or without meaning or intention. Physicians should reflect on whether aspects of their ritual interactions are undertaken on the basis of sentiment, custom or evidence-based outcomes, and whether rituals should be defended, continued in a modified fashion or even abandoned in favour of new behaviours suitable for and salient with contemporary practice in the interests of patient care.
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Affiliation(s)
- Mark H Arnold
- Sydney Medical Program, Faculty of Medicine and Health, University of Sydney, Camperdown, New South Wales, Australia
| | - Paul Komesaroff
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Ian Kerridge
- Sydney Health Ethics, School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
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9
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Tsehaie J, van der Oest MJW, Poelstra R, Selles RW, Feitz R, Slijper HP, Hovius SER, Porsius JT. Positive experience with treatment is associated with better surgical outcome in trapeziometacarpal osteoarthritis. J Hand Surg Eur Vol 2019; 44:714-721. [PMID: 31154893 PMCID: PMC6696737 DOI: 10.1177/1753193419851777] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The aim of this study was to investigate the association between patients' experiences with trapeziometacarpal arthroplasty and treatment outcomes in terms of patient-reported outcome measures, grip and pinch strength. We included 233 patients who received a Weilby procedure for trapeziometacarpal osteoarthritis. Before surgery and 12 months after surgery, patients completed the Michigan Hand Outcomes Questionnaire, and their pinch and grip strengths were measured. At 3 months after surgery, a patient-reported experience measure was completed. Using regression analysis, significantly positive associations were found between the Michigan Hand questionnaire and the patient-reported experience measure, with the strongest significant associations being for patients' experiences with information provision. No significant associations were found between the patients' experience and strength outcomes. The results highlight the potential importance of positive experience with the treatment process to improve treatment outcomes in patients undergoing surgery for trapeziometacarpal osteoarthritis. Level of evidence: IV.
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Affiliation(s)
- Jonathan Tsehaie
- Department of Plastic, Reconstructive
and Hand Surgery, Erasmus MC Rotterdam, The Netherlands,Hand and Wrist Surgery, Xpert Clinic,
The Netherlands,Department of Rehabilitation Medicine,
Erasmus MC Rotterdam, The Netherlands,Jonathan Tsehaie, Erasmus MC Rotterdam, Dr.
Molewaterplein 50, Room EE 15.91b, 3015 GE Rotterdam, The Netherlands.
| | - Mark J. W. van der Oest
- Department of Plastic, Reconstructive
and Hand Surgery, Erasmus MC Rotterdam, The Netherlands,Hand and Wrist Surgery, Xpert Clinic,
The Netherlands,Department of Rehabilitation Medicine,
Erasmus MC Rotterdam, The Netherlands
| | - Ralph Poelstra
- Department of Plastic, Reconstructive
and Hand Surgery, Erasmus MC Rotterdam, The Netherlands,Hand and Wrist Surgery, Xpert Clinic,
The Netherlands,Department of Rehabilitation Medicine,
Erasmus MC Rotterdam, The Netherlands
| | - Ruud W. Selles
- Department of Plastic, Reconstructive
and Hand Surgery, Erasmus MC Rotterdam, The Netherlands,Department of Rehabilitation Medicine,
Erasmus MC Rotterdam, The Netherlands
| | - Reinier Feitz
- Hand and Wrist Surgery, Xpert Clinic,
The Netherlands
| | | | - Steven E. R. Hovius
- Department of Plastic, Reconstructive
and Hand Surgery, Erasmus MC Rotterdam, The Netherlands,Hand and Wrist Surgery, Xpert Clinic,
The Netherlands
| | - Jarry T. Porsius
- Department of Plastic, Reconstructive
and Hand Surgery, Erasmus MC Rotterdam, The Netherlands,Hand and Wrist Surgery, Xpert Clinic,
The Netherlands,Department of Rehabilitation Medicine,
Erasmus MC Rotterdam, The Netherlands
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10
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Kravvariti E, Kitas GD, Mitsikostas DD, Sfikakis PP. Nocebos in rheumatology: emerging concepts and their implications for clinical practice. Nat Rev Rheumatol 2019; 14:727-740. [PMID: 30361674 DOI: 10.1038/s41584-018-0110-9] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Nocebo effects are noxious reactions to therapeutic interventions that occur because of negative expectations of the patient. In the past decade, neurobiological data have revealed specific neural pathways induced by nocebos (that is, interventions that cause nocebo effects), as well as the associated mechanisms and predisposing factors of nocebo effects. Epidemiological data suggest that nocebos can have a notable effect on medication adherence, clinical outcomes and health-care policy. Meta-analyses of randomized controlled trials (RCTs) of patients with rheumatic and musculoskeletal diseases (RMDs) indicate that withdrawal of treatment by placebo-arm participants owing to adverse events is common; a proportion of these events could be nocebo effects. Moreover, in large-scale, open-label studies of patients with RMDs who transition from bio-originator to biosimilar therapeutics, biosimilar retention rates were much lower than in previous double-blind switch RCTs. This discrepancy suggests that in addition to the lack of response in some patients because of intrinsic differences between the drugs, nocebos might have an important role in low biosimilar retention, thus increasing the need for awareness and early identification of nocebo effects by rheumatologists and allied health-care professionals.
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Affiliation(s)
- Evrydiki Kravvariti
- First Department of Propaedeutic Internal Medicine, Joint Rheumatology Program, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - George D Kitas
- Clinical Research Unit, Dudley Group NHS Foundation Trust, Dudley, UK.,Arthritis Research UK Centre for Epidemiology, University of Manchester, Manchester, UK
| | - Dimos D Mitsikostas
- First Department of Neurology, Aeginition Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Petros P Sfikakis
- First Department of Propaedeutic Internal Medicine, Joint Rheumatology Program, National and Kapodistrian University of Athens Medical School, Athens, Greece.
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11
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Miller SM. Occupational Pain Medicine: From Paradigm Shift in Pain Neuroscience to Contextual Model of Care. Front Hum Neurosci 2019; 13:188. [PMID: 31249517 PMCID: PMC6582749 DOI: 10.3389/fnhum.2019.00188] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Accepted: 05/22/2019] [Indexed: 11/13/2022] Open
Affiliation(s)
- Steven M Miller
- Perceptual and Clinical Neuroscience Laboratory, Department of Physiology, Monash Biomedicine Discovery Institute, School of Biomedical Sciences, Monash University, Melbourne, VIC, Australia.,Monash Alfred Psychiatry Research Centre, Central Clinical School, Monash University and Alfred Health, Melbourne, VIC, Australia
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12
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Keppel Hesselink JM, Kopsky DJ, Bhaskar AK. Ethical justification of single-blind and double-blind placebo-controlled response tests in neuropathic pain and N-of-1 treatment paradigm in clinical settings. J Pain Res 2019; 12:345-352. [PMID: 30679922 PMCID: PMC6338124 DOI: 10.2147/jpr.s180792] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
At our center in the Netherlands, patients, who very often are treatment resistant to the analgesics recommended in the guidelines, suffering from symmetrical peripheral neuropathic pain are treated exclusively. We have developed a number of compounded topical formulations containing classical co-analgesics such as ketamine, baclofen, amitriptyline, and phenytoin for the treatment of neuropathic pain in treatment-resistant patients. In order to identify putative responders and exclude an (initial) placebo-response, we developed single-blind and double-blind placebo-controlled response tests. The test can be performed when the patient has a symmetrical polyneuropathy with a pain score difference of not more than 1 point on the 11-point numerical rating scale (NRS) between bilateral pain areas. On one area (eg, left foot) the placebo cream and on the other area (eg, right foot) the active cream will be applied. Within a time frame of 30 minutes, patients are considered responders if they rate a pain difference of at least 2 points on the NRS between the bilateral areas on which the active cream and placebo cream are applied. Response tests can be easily conducted during the first consultation. In this paper, we explore the ethical context of using a placebo in clinical practice in a single-blind and double-blind fashion to improve and individualize treatment of neuropathic pain outside a context of a formal clinical trial.
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Affiliation(s)
| | - David J Kopsky
- Institute for Neuropathic Pain, Amsterdam, The Netherlands
| | - Arun K Bhaskar
- Pain Management Centre, Charing Cross Hospital Imperial Healthcare NHS Trust, London, UK
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13
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The effect of expectation on transcranial direct current stimulation (tDCS) to suppress food craving and eating in individuals with overweight and obesity. Appetite 2019; 136:1-7. [PMID: 30611756 DOI: 10.1016/j.appet.2018.12.044] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 12/29/2018] [Accepted: 12/29/2018] [Indexed: 12/15/2022]
Abstract
Transcranial direct current stimulation (tDCS) is a neuromodulation technique with potential to treat eating disorders and obesity. As for any potential treatment, it is important to assess the degree to which expectation effects contribute to its reported efficacy. This study assessed the effect of tDCS on amount of food craving and eating while tightly controlling treatment expectation. N = 74 adults with overweight or obesity were informed of the known effects of tDCS to suppress craving and eating. Once electrodes were on the head, half of the participants were told they were receiving real, and the other half sham tDCS. Within these groups, approximately half actually received real and the other half sham tDCS. Stimulation parameters used were those previously found to reduce craving and eating, including in our lab: 2 mA, anode right/cathode left targeting the dorsolateral prefrontal cortex for 20 min (real), or only for the first and last minute (sham). Analyses controlled for demographics, hunger, trait impulsiveness, eating motives, dieting, binge eating, suggestibility, and baseline craving and eating. Participants told they were receiving real tDCS craved and ate less than participants told they were receiving sham tDCS (both p < 0.01), regardless of tDCS condition administered. There was no main effect of real vs. sham tDCS on craving or eating or an interaction between tDCS condition and expectation. The scientific validation of tDCS as a treatment for eating-related conditions hinges on controlling for the powerful effects of expectation. This can include the type of information provided on consent forms and participants' ability to guess real from sham conditions.
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14
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Linden M, Wasilewski J. Better patient knowledge and worse treatment outcome after written patient information in inpatient cognitive behaviour therapy as compared to non-informed patients. COGENT PSYCHOLOGY 2019. [DOI: 10.1080/23311908.2019.1612825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Affiliation(s)
- Michael Linden
- Research Group Psychosomatic Rehabilitation, Charité University Medicine Berlin, Berlin, Germany
| | - Janice Wasilewski
- Research Group Psychosomatic Rehabilitation, Charité University Medicine Berlin, Berlin, Germany
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15
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Glintborg B, Loft AG, Omerovic E, Hendricks O, Linauskas A, Espesen J, Danebod K, Jensen DV, Nordin H, Dalgaard EB, Chrysidis S, Kristensen S, Raun JL, Lindegaard H, Manilo N, Jakobsen SH, Hansen IMJ, Dalsgaard Pedersen D, Sørensen IJ, Andersen LS, Grydehøj J, Mehnert F, Krogh NS, Hetland ML. To switch or not to switch: results of a nationwide guideline of mandatory switching from originator to biosimilar etanercept. One-year treatment outcomes in 2061 patients with inflammatory arthritis from the DANBIO registry. Ann Rheum Dis 2018; 78:192-200. [PMID: 30396903 DOI: 10.1136/annrheumdis-2018-213474] [Citation(s) in RCA: 103] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 10/10/2018] [Accepted: 10/16/2018] [Indexed: 12/15/2022]
Abstract
OBJECTIVES Real-world evidence on effectiveness of switching to biosimila r etanercept is scarce. In Denmark, a nationwide guideline of mandatory switch from 50 mg originator (ETA) to biosimilar (SB4) etanercept was issued for patients with rheumatoid arthritis (RA), psoriatic arthritis (PsA) and axial spondyloarthritis (AxSpA) in 2016. Clinical characteristics and treatment outcomes were studied in ETA-treated patients, who switched to SB4 (switchers) or maintained ETA (non-switchers). Retention rates were compared with that of a historic cohort of ETA-treated patients. Switchers who resumed ETA treatment (back-switchers) were characterised. METHODS Observational cohort study based on the DANBIO registry. Treatment retention was explored by Kaplan-Meier plots and Cox regression (crude, adjusted). RESULTS 1621 (79%) of 2061 ETA-treated patients switched to SB4. Disease activity was unchanged 3 months' preswitch/postswitch. Non-switchers often received 25 mg ETA (ETA 25 mg pens/syringes and powder solution were still available). One-year adjusted retention rates were: non-switchers: 77% (95% CI: 72% to 82%)/switchers: 83% (79% to 87%)/historic cohort: 90% (88% to 92%). Patients not in remission had lower retention rates than patients in remission, both in switchers (crude HR 1.7 (1.3 to 2.2)) and non-switchers (2.4 (1.7 to 3.6)). During follow-up, 120 patients (7% of switchers) back-switched to ETA. Back-switchers' clinical characteristics were similar to switchers, and reasons for SB4 withdrawal were mainly subjective. CONCLUSION Seventy-nine per cent of patients switched from ETA to SB4. After 1 year, adjusted treatment retention rates were lower in switchers versus the historic ETA cohort, but higher than in non-switchers. Withdrawal was more common in patients not in remission. The results suggest that switch outcomes in routine care are affected by patient-related factors and non-specific drug effects.
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Affiliation(s)
- Bente Glintborg
- The DANBIO registry and Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre of Head and Orthopaedics, Rigshospitalet, Glostrup, Denmark .,Department of Rheumatology, Gentofte and Herlev Hospital, Copenhagen University Hospital, Gentofte, Denmark
| | - Anne Gitte Loft
- Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Emina Omerovic
- Department of Rheumatology, Center for Rheumatology and Spine Diseases, Centre of Head and Orthopaedics, Rigshospitalet, Copenhagen University Hospital, Glostrup, Denmark
| | | | - Asta Linauskas
- Department of Rheumatology, North Denmark Regional Hospital, Hjørring, Denmark
| | - Jakob Espesen
- Department of Rheumatology, Vejle Hospital Lillebælt, Vejle, Denmark
| | - Kamilla Danebod
- Department of Rheumatology, Gentofte and Herlev Hospital, Copenhagen University Hospital, Gentofte, Denmark
| | - Dorte Vendelbo Jensen
- Department of Rheumatology, Gentofte and Herlev Hospital, Copenhagen University Hospital, Gentofte, Denmark
| | - Henrik Nordin
- Department of Rheumatology, Zealand University Hospital, Køge, Denmark
| | | | | | - Salome Kristensen
- Department of Rheumatology, Aalborg University Hospital, Aalborg, Denmark
| | | | - Hanne Lindegaard
- Department of Rheumatology, Odense University Hospital, Odense, Denmark
| | - Natalia Manilo
- Department of Rheumatology, Frederiksberg Hospital, Copenhagen, Denmark
| | | | | | | | - Inge Juul Sørensen
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,The DANBIO registry and COPECARE, Center for Rheumatology and Spine Diseases, Centre of Head and Orthopaedics, Rigshospitalet, Copenhagen University Hospital, Glostrup, Denmark
| | | | - Jolanta Grydehøj
- Department of Rheumatology, Holstebro hospital, Holstebro, Denmark
| | - Frank Mehnert
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Merete Lund Hetland
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,The DANBIO registry and COPECARE, Center for Rheumatology and Spine Diseases, Centre of Head and Orthopaedics, Rigshospitalet, Copenhagen University Hospital, Glostrup, Denmark
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L’effet Nocebo : particularités et conséquences pour le clinicien. Rev Med Interne 2018; 39:315-320. [DOI: 10.1016/j.revmed.2018.02.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Accepted: 02/26/2018] [Indexed: 11/21/2022]
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Abstract
The nocebo effect, the inverse of the placebo effect, is a well-established phenomenon, yet under-appreciated. It refers to nonpharmacological, harmful, or undesirable effects occurring after active or inactive therapy. The frequency of adverse events can dramatically increase by informing patients about the possible side effects of the treatment, and by negative expectations on the part of the patient. Patients who were told that they might experience sexual side effects after treatment with β-blocker drugs reported these symptoms between three and four times more often than patients in a control group who were not informed about these symptoms. Nocebo effect has been reported in several neurological diseases such as migraine, epilepsy, multiple sclerosis, Parkinson's disease and neuropathic pain, and in patients with depression. The investigation of the biological and theoretical underpinning of the nocebo phenomenon is at an early stage, and more research is required. Physicians need to be aware of the influence of nocebo phenomenon and be able to recognize it and minimize its effects.
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Affiliation(s)
- Majed Chamsi-Pasha
- Department of Medicine, King Fahd Armed Forces Hospital, Jeddah, Saudi Arabia
| | - Mohammed Ali Albar
- Department of Medical Ethics, International Medical Center, Jeddah, Saudi Arabia
| | - Hassan Chamsi-Pasha
- Department of Cardiology, King Fahd Armed Forces Hospital, Jeddah, Saudi Arabia
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18
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Hampshire K, Hamill H, Mariwah S, Mwanga J, Amoako-Sakyi D. The application of Signalling Theory to health-related trust problems: The example of herbal clinics in Ghana and Tanzania. Soc Sci Med 2017; 188:109-118. [PMID: 28738317 PMCID: PMC5559643 DOI: 10.1016/j.socscimed.2017.07.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 07/13/2017] [Accepted: 07/14/2017] [Indexed: 01/19/2023]
Abstract
In contexts where healthcare regulation is weak and levels of uncertainty high, how do patients decide whom and what to trust? In this paper, we explore the potential for using Signalling Theory (ST, a form of Behavioural Game Theory) to investigate health-related trust problems under conditions of uncertainty, using the empirical example of ‘herbal clinics’ in Ghana and Tanzania. Qualitative, ethnographic fieldwork was conducted over an eight-month period (2015–2016) in eight herbal clinics in Ghana and ten in Tanzania, including semi-structured interviews with herbalists (N = 18) and patients (N = 68), plus detailed ethnographic observations and twenty additional key informant interviews. The data were used to explore four ST-derived predictions, relating to herbalists' strategic communication (‘signalling’) of their trustworthiness to patients, and patients' interpretation of those signals. Signalling Theory is shown to provide a useful analytical framework, allowing us to go beyond the primary trust problem addressed by other researchers – cataloguing observable indicators of trustworthiness – and providing tools for tackling the trickier secondary trust problem, where the trustworthiness of those indicators must be ascertained. Signalling Theory also enables a basis for comparative work between different empirical contexts that share the underlying condition of uncertainty. Applies Signalling Theory (ST) to patient-herbalist trust in Ghana & Tanzania. Herbalists communicate trustworthiness to patients via observable ‘signals’. Patients interpret signal reliability based on perceived costs and pay-offs. In conditions of uncertainty, informational mismatches result in misplaced trust. ST allows us to go beyond description, enabling prediction and comparative work.
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Affiliation(s)
| | | | - Simon Mariwah
- Dept of Geography and Regional Planning, University of Cape Coast, Ghana
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19
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Arnold MH, Bleasel J, Haq I. Nocebo effects in practice: methotrexate myths and misconceptions. Med J Aust 2017; 205:440-442. [PMID: 27852171 DOI: 10.5694/mja16.00965] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Accepted: 09/05/2016] [Indexed: 12/11/2022]
Affiliation(s)
- Mark H Arnold
- School of Rural Health, University of Sydney, Dubbo, NSW
| | - Jane Bleasel
- Office of Medical Education, University of Sydney, Sydney, NSW
| | - Inam Haq
- Office of Medical Education, University of Sydney, Sydney, NSW
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20
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Does brief chronic pain management education change opioid prescribing rates? A pragmatic trial in Australian early-career general practitioners. Pain 2016; 158:278-288. [DOI: 10.1097/j.pain.0000000000000755] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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21
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Mancini GJ, Baker S, Bergeron J, Fitchett D, Frohlich J, Genest J, Gupta M, Hegele RA, Ng D, Pearson GJ, Pope J, Tashakkor AY. Diagnosis, Prevention, and Management of Statin Adverse Effects and Intolerance: Canadian Consensus Working Group Update (2016). Can J Cardiol 2016; 32:S35-65. [DOI: 10.1016/j.cjca.2016.01.003] [Citation(s) in RCA: 160] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Revised: 01/03/2016] [Accepted: 01/05/2016] [Indexed: 12/24/2022] Open
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Marshall GRE, Hooker C. Empathy and affect: what can empathied bodies do? MEDICAL HUMANITIES 2016; 42:128-134. [PMID: 26856355 DOI: 10.1136/medhum-2015-010818] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/13/2016] [Indexed: 06/05/2023]
Abstract
While there has been much interest in the apparent benefits of empathy in improving outcomes of medical care, there is continuing concern over the philosophical nature of empathy. We suggest that part of the difficulty in coming to terms with empathy is due to the modernist dichotomies that have structured Western medical discourse, such that doctor and patient, knower and known, cognitive and emotional, subject and object are situated in oppositional terms, with the result that such accounts cannot coherently encompass an emotional doctor, or a patient as knower, or empathy as other than a possession or a trait. This paper explores what, by contrast, a radical critique of the Cartesian world view, in the form of a Deleuzean theoretical framework, would open up in new perspectives on empathy. We extend the framework of emotional geography to ask what happens when people are affected by empathy. We suggest that doctors and patients might be more productively understood as embodied subjects that are configured in their capacities by how they are affected by singular 'events' of empathy. We sketch out how the Deleuzean framework would make sense of these contentions and identify some possible implications for medical education and practice.
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Affiliation(s)
| | - Claire Hooker
- Centre for Values, Ethics and Law in Medicine, University of Sydney, Sydney, New South Wales, Australia
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23
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Beales D, Fried K, Nicholas M, Blyth F, Finniss D, Moseley GL. Management of musculoskeletal pain in a compensable environment: Implementation of helpful and unhelpful Models of Care in supporting recovery and return to work. Best Pract Res Clin Rheumatol 2016; 30:445-467. [DOI: 10.1016/j.berh.2016.08.011] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Revised: 08/26/2016] [Accepted: 08/27/2016] [Indexed: 10/20/2022]
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24
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Carlino E, Benedetti F. Different contexts, different pains, different experiences. Neuroscience 2016; 338:19-26. [PMID: 26827944 DOI: 10.1016/j.neuroscience.2016.01.053] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2015] [Revised: 01/21/2016] [Accepted: 01/22/2016] [Indexed: 12/19/2022]
Abstract
Pain is an ambiguous perception: the same pain stimulation can be perceived differently in different contexts, producing different experiences, ranging from mild to unbearable pain. It can be even experienced as a rewarding sensation within the appropriate context. Overall, placebo and nocebo effects appear to be very good models to understand how the psychosocial context modulates the experience of pain. In this review, we examine the effects of different contexts on pain, with a specific focus on the neurobiological mechanisms. Positive and rewarding contexts inform the patients that an effective treatment is being delivered and are capable of producing pain relief through the activation of specific systems such as opioids, cannabinoids and dopamine. Conversely, a negative context can produce pain exacerbation and clinical worsening through the modulation of different systems, such as the activation of cholecystokinin and the deactivation of opioids and dopamine. In addition, when a therapy is delivered unbeknownst to the patient, its effects are reduced. A better understanding of the neurobiological underpinnings of the context-pain interaction is a challenge both for future pain research and for good clinical practice.
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Affiliation(s)
- E Carlino
- University of Turin Medical School, Neuroscience Department, Turin, Italy
| | - F Benedetti
- University of Turin Medical School, Neuroscience Department, Turin, Italy; Plateau Rosa Laboratories, Breuil-Cervinia, Italy, Zermatt, Switzerland.
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25
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Hooker C. Understanding empathy: why phenomenology and hermeneutics can help medical education and practice. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2015; 18:541-52. [PMID: 25763825 DOI: 10.1007/s11019-015-9631-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
This article offers a critique and reformulation of the concept of empathy as it is currently used in the context of medicine and medical care. My argument is three pronged. First, that the instrumentalised notion of empathy that has been common within medicine erases the term's rich epistemological history as a special form of understanding, even a vehicle of social inquiry, and has instead substituted an account unsustainably structured according to the polarisations of modernity (subject/object, active/passive, knower/known, mind/body, doctor/patient). I suggest that understanding empathy by examining its origins within the phenomenological tradition, as a mode of intersubjective understanding, offers a different and profitable approach. Secondly, I argue that the appropriation of empathy in medicine means that, ironically, empathy can function as a technique of pastoral power, in which virtue, knowledge and authority remain with the doctor (Mayes in Bioeth Inq 6:483-493, doi: 10.1007/s11673-009-9195-9 , 2009). And thirdly, empathy is in danger of being resourced as a substitute for equity and funding within health systems. I conclude however with hope for the productive possibilities for empathy.
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Affiliation(s)
- Claire Hooker
- Centre for Values, Ethics and Law in Medicine, University of Sydney, K25, Sydney, NSW, 2006, Australia.
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27
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Gandhi RA, Selvarajah D. Understanding and treating painful diabetic neuropathy: time for a paradigm shift. Diabet Med 2015; 32:771-7. [PMID: 25818649 DOI: 10.1111/dme.12755] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/19/2015] [Indexed: 12/23/2022]
Abstract
The pathogenesis of diabetic neuropathy (DN) continues to be unclear and as a result, progress in developing effective therapies has been disappointing. In particular, there is only limited understanding of why some patients suffer severe chronic pain, whilst others have painless symptoms. Assessment of the peripheral nerves frequently shows no differences between painful and painless DN. There is growing evidence that the nerve damage in DN is more generalized, including the central nervous system, and these central changes are key to the development and persistence of pain in DN. The advent of new radiological techniques provides us with non-invasive modalities to study central pathophysiological processes in greater detail. These insights are increasingly leading to the recognition that painful DN is a complex and heterogeneous disorder, which requires a multimodal approach to treatment.
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Affiliation(s)
- R A Gandhi
- Academic Unit of Diabetes, Endocrinology and Metabolism, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - D Selvarajah
- Academic Unit of Diabetes, Endocrinology and Metabolism, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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28
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Kaufman KR. Ethical considerations in placebo-controlled randomised clinical trials. BJPsych Open 2015; 1:e3-e4. [PMID: 27703733 PMCID: PMC5000495 DOI: 10.1192/bjpo.bp.115.000919] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Accepted: 05/01/2015] [Indexed: 11/23/2022] Open
Abstract
SUMMARY Ethical considerations in standard medical care and clinical research are underpinnings to quality medicine. Similarly, the placebo-controlled double-blind randomised clinical trial is the gold standard for medical research and fundamental to the development of evidence-based medicine. Researchers and clinicians are challenged by ethical concerns in the informed consent with a need to maximise understanding and minimise therapeutic misconception. This editorial expands on themes raised by Chen et al's article 'Disclosing the Potential Impact of Placebo Controls in Antidepressant Trials' and serves as an invitation for further submissions to BJPsych Open on ethics, research design and informed consent. DECLARATION OF INTEREST None. COPYRIGHT AND USAGE © The Royal College of Psychiatrists 2015. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) licence.
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Affiliation(s)
- Kenneth R Kaufman
- , MD, MRCPsych, Departments of Psychiatry, Neurology and Anesthesiology, Rutgers Robert Wood Johnson Medical School, 125 Paterson Street, Suite #2200, New Brunswick, NJ 08901, USA.
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