Science and Law
7th June 2013

The Nocebo Defense

About fifteen years ago, a Tennessee high school was evacuated after a teacher smelled a gasoline-like odor and began experiencing dizziness, nausea and a headache. Eighty students and nineteen staff members who also fell ill were taken to the ER, and thirty-eight of them were hospitalized overnight.

The Nocebo Defense

About fifteen years ago, a Tennessee high school was evacuated after a teacher smelled a gasoline-like odor and began experiencing dizziness, nausea and a headache. Eighty students and nineteen staff members who also fell ill were taken to the ER, and thirty-eight of them were hospitalized overnight. However, an extensive investigation found no medical or environmental explanation for the illnesses.

This incident is a classic example of the insidious nocebo effect at work.

Defense lawyers often encounter plaintiffs who complain of an illness they attribute to a particular product, despite the lack of reasonable scientific evidence linking the symptoms described to the product. In many cases, there are countless potential causative agents, making determining causation virtually impossible. But one possible explanation is the nocebo effect.

The nocebo effect is known as the placebo effect’s evil twin. The placebo effect refers to a positive health outcome that results from a patient’s belief that a treatment will be effective. Conversely, the nocebo effect occurs when an individual experiences an adverse outcome caused by their belief that an agent – such as a chemical exposure, placebo or sham treatment – is harmful. In other words, the power of suggestion can lead to illness when an individual believes they have been exposed to contaminants or a medication with potential side effects.

The nocebo effect may be a major contributor to the high rate of psychogenic illness at the center of many lawsuits, as comments from the plaintiff’s attorney, expert witnesses, and advocacy groups can reinforce the plaintiff’s expectation of adverse health outcomes, according to Nathan Schachtman, Esq. The nocebo effect causes complications for the tort system, as warnings can actually create harm.

In the absence of solid scientific evidence that a product caused the plaintiff’s illness, the defense team can implicate the nocebo effect with the assistance of an expert witness, ideally a clinical toxicologist. Clinical toxicologists are MDs who are qualified to offer medical opinions on specific causation and general causation. Experts from other medical and scientific disciplines – such as neurology, rheumatology and psychology – can also offer supporting testimony on the nocebo effect as it relates to specific products or exposures.

When building your nocebo defense, it can be helpful to present compelling background information on this powerful phenomenon:

• The nocebo effect appears in clinical trials.

The nocebo effect has been well documented in clinical trials, representing powerful evidence for the defense. For instance, patients receiving a placebo often experience adverse side effects attributed to the patient’s expectations, which may be influenced by prior experiences, a psychological predispositions to anxiety or depression, or situational and contextual factors. The nocebo effect can complicate clinical trials because researchers may erroneously attribute side effects to the treatment. In one study that attempted to account for the nocebo effect, only 10.9% of side effects were clearly attributable to medications commonly prescribed in primary care settings, while 68.7% were “probably” related, and 20.3% were “possibly” related.

• The nocebo effect leads to mass psychogenic illness.

Exposure to chemicals at insignificant levels often leads to public health concerns within the affected community. One study addressed to the public’s concerns about adverse health effects associated with emissions from a new road tunnel exhaust stack, despite the absence of a demonstrable change in local air quality. The authors examined the association between exposure to the exhaust stack emissions and the presence of eye, nose and throat symptoms. They found the presence of eye, nose and throat symptoms in 50%, 67% and 33% of respondents, respectively, but the percentage rates did not differ among the high, medium and low exposure zones. They concluded that the symptoms were attributable to “environmental worry.”

• The nocebo effect causes concerns about modern technology.

The increasing adoption of new technologies in our society has led to concerns about negative health effects. Studies show that individuals with high levels of concern about adverse health effects from modern technology experience more symptoms. The news media’s focus on the perceived health hazards related to technology may increase an individual’s anxiety. In one study, investigators assessed whether media reports promote the development of idiopathic environmental intolerance attributed to electromagnetic fields. The authors found that media reports about the adverse effects of putatively hazardous exposures can increase the likelihood of experiencing symptoms following sham- or non-exposure.

 

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