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Hydroxychloroquine: Placebo or Nocebo?

Updated: Aug 8, 2020

I am fortunate in that my primary physician is also a friend. Fortunate, in that as friends, we communicate beyond the treatment of my various aches, pains, prostate exams, and the other things that go wrong when decay sets in. We discuss current events and sometimes even swerve into politics. But being like-minded, we keep the go-kart on the road, and with his outsized sense of humor, we always end in laughter.

On one recent visit, we discussed the use of Hydroxychloroquine, the controversial anti-malaria medication in treating the symptoms of COVID-19. My doctor’s medical school specialty was epidemiology, the branch of medicine which deals with the incidence, distribution, and possible control of diseases and other factors relating to health. So when he talks, I best listen.

On that day, I only dared argue one point with him. “Doc, since it appears that those treated with Hydroxychloroquine believe they benefited from the drug, even if it were from the placebo effect, why not prescribe it?” The good doc, always gentle, carefully explained that it is unethical for doctors to prescribe a medication knowing there is no actual medicinal benefit. “Of course, of course,” I mutter as I slither off the exam table a tad embarrassed for having even suggested an unethical approach. I try to recover with a little humor.

The man told his doctor that he wasn’t able to do all the things around the house that he used to do. When the examination was complete, he said: “Now, Doc, I can take it. Tell me in plain English what is wrong with me.”
“Well, in plain English,” the doctor replied, “you’re just lazy.”
“Okay,” said the man. “Now give me the medical term so I can tell my wife.”

The idea of the ‘placebo’ effect stuck with me. There is little doubt as to its efficacy. Many studies have proven that if someone believes a pill will provide benefit, then indeed it does — even an inert sugar pill. Not always, but the statistics are surprising.

This all points to the wonder and complexity of our human imagination. The imagined cure exposes a psychological curiosity we know as the ‘power of suggestion.’ We imagine the benefit of a pill, or even a suggestion of a positive outcome, and it becomes our experience.

Many prescribed Hydroxychloroquine tell of the fever subsiding, a sense of well-being returning, and being cured. In the case of Hydroxychloroquine, it is also possible the actual medication made a physiological contribution to the recovery (when asked, over 60 percent of front-line physicians would prescribe Hydroxychloroquine to family members to combat COVID-19).

If the power of suggestion is indeed powerful, what if the suggestion was not of a positive outcome, but rather a negative outcome. Is there such a thing as a negative placebo effect?

There is. A suggestion can be either positive or negative. A negative suggestion can invoke the ‘nocebo effect.’ An example would be if an individual is told that a sugar pill will have nasty side effects, and then actually experiences those effects. This, too, raises an interesting ethical question. How much should a medical professional tell of potentially unpleasant side effects when treating a patient with, let’s say, chemotherapy, radiation, or invasive surgery? With the mere suggestion of a particular outcome, that outcome becomes more likely.

Oh… my. We are complicated creatures, aren’t we?

We only get more complicated. It goes without saying that we humans always consider the ‘source’ when assessing a suggestion’s validity. If my doctor and friend suggest a particular medical outcome, positive or negative, I will nearly always believe him. If my doctor gives me a pill and tells me I’ll feel better in the morning, and I do, I don’t care if he gave me a placebo. He just has that much credibility. I believe him.

But what if a crude loathsome uncle, who I pathologically hate with all my being, offers up a spoonful of grandma’s magic brew and tells me I’ll feel better in the morning? I’ll likely throw it in his face, turn and run while yelling, “He’s trying to kill me! He’s trying to kill me!”

Let’s take our complexity one step further. What if the President of the United States suggests that Hydroxychloroquine might offer some benefit in the fight against COVID-19? Considering the partisan nature of our body politic and the minions who pathologically hate him, it was no surprise that his suggestion would elicit the kind of response it did. Of course, his acolytes would quickly become believers. Little did he know, but he was suggesting what might be both a placebo and a nocebo.

Some found ‘hope’ in his suggestion. Many would report the healing powers of Hydroxychloroquine. Others scorned the idea. They went about feverishly to prove the drug as either ineffective or worse, deadly.

Even researchers, the scientist, when holding an ideological commitment to a certain outcome, will do more work to make sure everything adds up to their predetermined outcome. Much of the Hydroxychloroquine research was tossed out by peer review as being shoddy. Small samplings. The medication was given near-death etc., etc.

Some in the media couldn’t help themselves either. If a researcher suggested how a combination of medications and medical conditions might lead to death, then Hydroxychloroquine became a drug of death. When a group of doctors appeared on a YouTube video promoting its ‘healing’ possibilities, they were de-platformed as if their beliefs would lead many to die. The lead spokesperson, a black female doctor from Nigeria, was rhetorically fileted when some folks discovered that she once included ‘devil’ in a medical sentence. As cultural practices clash and in stereotypical fashion, we conjure up an image of a jungle shaman practicing voodoo medicine.

Oh… my. We are complicated creatures, aren’t we?

The Hydroxychloroquine controversy illustrates our capacity to hold such strong ideological commitments, we’ll do anything to make sure that our predetermined outcome actually occurs. The end has been preordained, we must just manipulate the means. Rather Machiavellian, don’t you think?

Our world view, the formation of our biases and stereotypes, and who we choose to trust or hate, is wonderfully complex- Nearly as breathtaking as standing at the cliff edge of the Grand Canyon for the very first time. To get to the other side appears to be nearly impossible. Be careful.

I’m looking forward to talking to my doctor. I have a few more questions. I trust him.

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