Nocebo: the power of suggestibility.

A useful way to summarize the placebo-nocebo theme is to consider the tension and interaction between conviction and responsibility. With the conviction of the mainstream biomedical paradigm prevalent today, it would be tempting to say to Dr. Engel's patient: "That question is nonsense. Cancer pain is not classified as 'male' or 'female.' Pain varies with location in the body and other factors." This response is technically honest but, in effect, it would have the impact of a nocebo. It would impair the patient's hope and morale. The doctor's honesty and conviction would serve as blinders to the patient's suffering. This type of honest statement results in a diminished sense of responsibility for the patient's well-being. Taking the biopsychosocial context into account, Dr. Engel achieved a balance between conviction and responsibility. The patient's question was understood within the meaning and metaphorical terms of her belief system. He answered in a manner that respected her private point of view toward pain and tapped her suggestibility, guiding her toward a probable placebo effect. "Female cancer" resonated with her personal beliefs and wish for less pain. Engel was both true to his convictions and responsible for providing the highest standard of care by understanding the patient's convictions and needs for comfort. The biopsychosocial concept provides a blueprint to bring the old-fashioned medical art of "humanness" to modern scientific care. Identifying the interactions of the problem, the person, and the totality of resources permits a focus on therapeutic strategies to promote placebo effects and prevent the consequences of nocebo.