Ada S. Jaarsma and Suze G. Berkhout
Ada S. Jaarsma is a Professor of Philosophy at Mount Royal University in Calgary, where she teaches existential philosophy, philosophy of science, and philosophy of sex and love. Her recent books are Dissonant Methods: Undoing Discipline in the Humanities Classroom, co-edited with Kit Dobson, and Kierkegaard after the Genome: Science, Existence, and Belief in This World. She holds a SSHRC Insight grant, “Placebos Talk Back,” and is working on a collaborative, transdisciplinary project on placebos.
Suze G. Berkhout is a clinician-investigator and psychiatrist at the University of Toronto and University Health Network. Her program of research in feminist philosophy of science/STS uses ethnographic and narrative qualitative methods to explore social and cultural issues that have an impact on access and navigation through health care systems. She focuses on the epistemic and ontological importance of lived experience in relation to knowledge in/of medicine, and related to mental health, including treatment resistance in mental health, early psychosis, transplant medicine, and placebo/nocebo studies.
Decartes video animation: Eva-Marie Stern & Maya Morton Ninomiya
Overcoming the mind/body split by reflecting on the ethical stakes of dualisms
Cartesianism is the shorthand term used to categorize ideas that reflect the 17th-century philosophy of René Descartes. Precisely because Descartes’s approach to knowledge continues to shape ideas today, his last name has become a placeholder for particular knowledge claims. Whenever there are specific dualisms at play in an argument or method, they can be described as “Cartesian.” A dualism is a binary or a split; it works to keep separate two entities or dynamics, like subjectivity and objectivity. The most famous dualism that lines up with Cartesianism is the mind/body dualism.
Descartes upheld a ‘theory of mind’, in which the body is entirely separate from the mind. In many cases, it is tempting for researchers—and for members of the public—to assume that this Cartesian theory from long ago is still valid today. Contemporary theorists like M. Remi Yergeau, who is a Disability Studies scholar, lay out a competing theory of mind in which bodies and minds are entirely entangled with each other.
The adjective, “Cartesian,” can be used as a neutral descriptor to point out ideas that align with Descartes’s, but more often, it is used as a criticism or a corrective. One reason for the negative association between Descartes’s ideas and contemporary research has to do with the impact of dualisms themselves. Dualisms like the mind/body split can be so prevalent that they can be hard to recognize, and even harder to overturn and replace with methods that affirm dynamic connections between bodies and minds.
When researchers study things without interrogating their own Cartesian commitments, it can lead to faulty or even prejudicial research methods. Consider the case of the placebo effect, in which a placebo (like a sugar pill, a doctor’s white coat, or a sham surgery) might prompt palpable healing in a patient. The Cartesian mind/body dualism can block a researcher’s capacity to study these dynamics: they might refer, for example, to the ‘mere’ placebo, a phrase that locates placebos “only in the mind” of patients rather than in real-world interactions between patients, treatments, bodies, and minds.
Such phrases can pose risks to research methods because, as Bruno Latour explains, they set minds (or representation) in competition with bodies (or even reality itself). Latour offers an instructive way to make sense of this competition: he calls it a “zero-sum understanding” of minds and bodies (2004, p. 8). Whenever Cartesian dualisms are at play, there can only ever be competition between minds and reality. Thanks to decades of research in cognitive science, disability studies, science studies, and other disciplines, we now understand that our minds are not separate from our bodies, nor are they in competition with reality. Research methods are developing that take cues from this understanding. Margaret Price, for example, suggests that we use the word “bodymind” to overthrow the dualism all together (2014).
This suggestion is an ethical and methodological one. There can be both harmful and healing effects that arise from interactions between physicians and patients. When a patient is advised that they might experience a negative side effect from a treatment, for example, even if that treatment happens to be a placebo, they may well develop the adverse (unpleasant or negative) symptom: this is called a nocebo effect. Similarly, when someone has experienced trauma in medical (or medicalized) settings, they might experience nocebo effects in medical situations in the future.
The ethical stakes of nocebos extend to the methods by which patients are told about potential side effects, as well as to the affects and relational dynamics between doctors and patients, and to the designs of spaces like doctors’ offices and medical institutions. More broadly, the ethical stakes of Cartesian dualisms extend to the very assumption of who gets to count as human in the first place. If “human personhood” is tied closely to particular kinds of consciousness or cognitive capacity, then lines can get drawn around who is and who is not “conscious,” ultimately informing who is (and is not) deserving of ethical consideration as human.
Watch the three videos in the following order:
1. Descartes’ First Three Meditations
2. Lessons from the Nocebo Effect
3. Unpacking “Lessons from the Nocebo Effect”: A conversation with the artists
To read the video transcripts, see below.
In the first video, we travel back to 1641, the year in which Descartes wrote his Meditations, where we discover two thought experiments Descartes would like us to undertake, from our own first-person perspectives. As a first thought experiment, notice how you might be deceived by your own senses. (Note that this experiment goes against the grain, almost completely, of empirical research methods, in which the senses are key for achieving reliable knowledge.) Can you think of an example in which one of your senses led you astray? As a second thought experiment, reflect on whether you have ever been deceived by a charismatic or ‘evil’ genius. Updating Descartes to our own era, can you think of someone, perhaps a famous influencer or expert, who convinced you of something that you later realized was false? Thinking through these two hypotheses from Descartes’s first three Meditations is a way to experience how or why Descartes’s ideas have proven compelling for centuries. Descartes’s enthusiasms about doubting are connected to humanist presumptions about freedom: if you can ‘think,’ then you can doubt and demonstrate your own essential freedom as a human.
In the second video, we move all the way into the present day, in which biomedical research into the placebo effect has led to additional research into the nocebo effect. Such research helps us to question and overturn Cartesian dualisms. This video was initially created for psychiatry residents at the University of Toronto, who needed to learn more about the ethical stakes of their own clinical work. What do you think is the key lesson for the psychiatry residents in this video? How would you explain the ethical significance of nocebos, in your own words?
In the third video, we hear from the artists who designed and drew the animation for the video, “Lessons from the Nocebo Effect,” Eva-Marie Stern and Maya Morton Ninomiya. They explain the various choices that they made, as they worked together to try to visualize the nocebo effect in ways that illuminate rather than obscure bodymind connections. Did this conversation with the artists change your own initial impressions of the nocebo animation in any way? Which choice did you find the most effective, in terms of visualizing the bodymind connections? How is the theory of mind, visualized by these artists, different from the 17th-century theory of mind that you encountered in the Descartes video?
- One way to understand a philosophy like Descartes’s is to think it through from your own first-person perspective. This way, you can do the very thing that Descartes is promising that you can do: namely, to doubt. It’s challenging, though, to doubt every single thing in your mind, especially because some forms of knowledge feel or seem so convincing. What form of skepticism seems more important to you: questioning the knowledge that comes from your senses or questioning the knowledge that comes from external sources of authority?
- Had you ever heard of the nocebo effect, before reading this text? The term “nocebo” was coined in the 1960s, as a way to name something that had been puzzling biomedical researchers: some participants in clinical research trials who were part of placebo control groups were developing the very side effects that the ‘real’ treatment could produce in people. This phenomenon was like the opposite of the placebo effect, because an inert or non-pharmacological treatment was able to elicit real, embodied symptoms. Thanks to the emerging field of Nocebo Studies, we now know a lot more about the many kinds of interactions and experiences that can lead to nocebo effects. Can you think of experiences in your own life in which the markers of authority (a white lab coat, or a medical brochure that describes potential side effects) might have translated into negative or adverse symptoms in your own bodymind?
- One of the challenges described by the artists who made the video, “Lessons from the Nocebo Effect” (see below), concerns the prevalence of Cartesian dualisms in contemporary neuroscience. After watching the video, what do you think about the artists’ strategies for depicting neuroactivity as biocultural and embodied, instead of entirely separate from the body? Did the artists’ reflections change your own mind about how you imagine or make sense of brain activity?
- At the end of the third video (see below), we hear the artist declare, “I love how the way you convey something is at least as important as what you convey.” Earlier, she makes a similar declaration: “The medium is the message.” These statements get to the heart of the problem of Cartesian dualisms. What are the ethical stakes of how the body-mind connection is depicted, visualized, or theorized? Put differently, what kinds of exclusions emerge from Cartesian assumptions about consciousness or other key aspects of cognitive phenomena?
Descartes, Rene. (2008). Meditations on First Philosophy. Oxford, UK: Oxford University Press.
Jaarsma, Ada S. and Suze G. Berkhout. (2019). Nocebos and the Psychic Life of Biopower. Symposium, 23(2): 67-93.
Berkhout, Suze G. and Ada S. Jaarsma. (2018). Trafficking in Cure and Harm: Placebos, Nocebos and the Curative Imaginary. Disability Studies Quarterly. 38(4).
Bernstein, Michael H., Cosima Locher, Tobias Kube, Sarah Buergler, Sif Stewart-Ferrer, and Charlotte Blease. (2020). Putting the ‘Art’ into the ‘Art of Medicine’: The Under-Explored Role of Artifacts in Placebo Studies. Frontiers in Psychology. 11. doi: 10.3389/fpsyg.2020.01354
Latour, Bruno. (2004). How to Talk about the Body? The Normative Dimension of Science Studies. Body & Society. 10(2-3): 205-229.
Price, Margaret. (2014) The Bodymind Problem and the Possibilities of Pain. Hypatia 30(1): 268-284.
Shelvin, Henry, and Phoebe Friesen. (2020). Pain, Placebo, and Cognitive Penetration. Mind & Language. DOI: 10.1111/mila.12292
Ventriglio, A., and D. Bhugra. (2015). Descartes’ Dogma and Damage to Western Psychiatry, Epidemiology and Psychiatric Sciences. 24(5): 368-370.
Yergeau, Melanie. (2013). Clinically Significant Disturbance: On Theorists who Theorize Theory of Mind,” Disability Studies Quarterly. 33(4).
Descartes’s Meditations (1641)
Descartes’ “Meditations” was written a long time ago, but in a lot of ways, it was written to you as a modern thinker. Descartes writes, “I marvel at how prone my mind is to errors.” And what he’d really like to do is invite you to marvel at the very same thing: to marvel at the errors in your own mind.
As a student, you’re likely already pretty good at this. Isn’t it true, for example, that a lot of the opinions that you held on to when you were young are no longer all that convincing or even plausible? But here’s the problem that Meditation One wants us to grapple with. It’s the problem of being deceived by our own senses. “Surely,” Descartes writes, “whatever I had admitted until now as most true, I received either from the senses or through the senses.” How can we find a way to question those truths that seems so certain, precisely because they stem from our own perceptions and sensations? [00:01:00] Descartes gives us a pretty creative method, which is to hypothesize that we’re dreaming. We’re not even awake. Of course, potentially our taste buds are lying to us, if we think that a strawberry tastes delicious, if it’s happening in a dream. This is a great way to prompt some doubt that wouldn’t otherwise take place.
But notice that Descartes is relying on an idea of thinking that is not how we think about thinking. He’s writing in 1641, almost 400 years ago. And he is envisioning our minds as containers. They are containers for one important thing: ideas. Everything we think is an idea, an idea in our mind. I might taste that strawberry, but, on Descartes’ philosophy, what’s really happening is that everything in the mind is having an idea. Including even the idea that came from a sensation.
We can simplify this by laying out his claims. He writes, “Nothing can exist in the mind of which the mind [00:02:00] is not conscious.” This is centuries before Freud gave us a way to think about the unconscious” ideas we don’t have access to. For Descartes, if something is in the mind, then it is an idea that is present to us, which means it’s up to us to figure out which ideas represent reality and which do not.
Descartes wants us to find a way to question everything we hold in our minds, so that we can build up knowledge again, based on the certainties that we discover. And so here’s the second problem: some ideas in our minds, they just seem so logical, like say basic math equations. But they are almost impossible to question. Descartes asks, “Since I judge that others sometimes make mistakes in matters that they believe they know most perfectly, may I not in like fashion be deceived, every time I add two and three?”
He knows that “two plus three” is very difficult to doubt. It just seems so correct that these numbers add [00:03:00] up to five! And so here he gives us another creative way to doubt: it’s another hypothesis or thought experiment. “Maybe there’s an evil genius. Maybe I have been deceived into thinking that ‘two plus three equals five’ by some kind of charismatic, brilliant deceiver.” This leads Descartes to affirm a pretty amazing kind of freedom. He writes, “Even if it is not within my power to know anything is true, it’s certainly is within my power to take care resolutely, to withhold my assent to what is false.” The one power no one can take away from me is the power of doubting: witholding assent to what is false.
In meditation Two, we find the claim that people tend to be referring to when they use the word “Cartesian,” which is just the adjective form of Descartes’ last name. Descartes writes, “This ‘I,’ that is, the soul by which I am what I am, is entirely distinct from the body [00:04:00] and would not fail to be what it is, even if the body did not exist.” Descartes is really famous for this claim: that there’s such a divide between the mind and the body that I would still be who I am, even if my body wasn’t there at all. A lot of people do not like this claim, that the mind and the body are completely separate, that only the mind is important, but it enables Descartes to make his key epistemological, meaning referring to knowledge, his key claim.
He writes, “I can make a judgment only about things that are known to me. I know that I exist.” The very fact that I am doubting means that I am demonstrating at last something certain, which is that I exist! I think, therefore I am! The Latin word he uses here is “cogito.” This is the discovery that I am a thinking thing. It’s the discovery of the cogito.
And this brings us to the third meditation. I exist, Descartes writes, and therefore God exists. Wait, how does this [00:05:00] logic go? He is busy taking an inventory of every idea in his mind, and he notices an idea that he could not have come up with himself. It’s the idea of perfection. Who is great enough to have caused such an idea? It must’ve been God, the only perfect being Descartes can imagine.
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Lessons from the Nocebo Effect
Have you ever noticed that sometimes, when you’re starting someone on a medication, they seem to improve with just that first dose or even that their assessment and being handed the prescription starts to shift their mood in the right direction? “The placebo effect” is the term to describe this phenomenon.
“Placebo” comes from Latin, meaning, “it will please.” The word is used to describe scenarios in which our bodies declare what we believe we know about what heals: we get better just by visiting the doctor’s office, or even by ingesting a sugar pill. The doctor’s white coat, the institutional setting, the [00:01:00] diplomas on the wall: these symbols communicate messages of help, health and healing.
They intersect with common sensical beliefs in what works. For example, that two pills are stronger than one, or that brand names are better than generic. These symbols also intersect with how the message is delivered. And we really do get better. The placebo effect sees those positive beliefs change and shift our physiology.
But there is a darker side to this story. Decades ago, medical practitioners also observed that adverse effects arose even when patients received inert treatments, such as the sugar pill that are commonly used in the control arm of a clinical trial. The control arm participants would get the very same side effects as the treatment. Just after [00:02:00] hearing about the possibilities of those adverse outcomes, the term “nocebo” was coined, a twist on the centuries-old placebo, sometimes called placebo’s evil twin.
The nocebo effect is the embodiment of anxiety, pain and distress. These effects are generated through anticipation and expectation of a negative outcome, particularly in healthcare settings. For some groups of people, the diplomas on the wall, the clipboard, the examination table, or even the psychiatrist couch are symbols of trauma, suffering, powerlessness, and distress.
They do not demarcate help or healing or positive aspect. Nocebo effects are now studied in their own right and through a range of [00:03:00] experimental models. But we can draw on our own clinical experience to think about when we see them. In psychiatry, nocebo effects are prominently seen within the practice of informing patients about potential risks of treatments or interventions, through an informed consent process, which is meant to protect patients from harm. The explicit mention of side effects generates an expectation of harm that can produce the very harms being warned of. We often hear that patients who are nervous about starting a medication are more likely to have every side effect that you list.
So what do you do? Informed consent is a central tenet of ethical clinical practice. It is how we operationalize respect for persons, which is the foundation of the principle of autonomy. But with the [00:04:00] nocebo effect, we get a clash of principles. Informed consent as an instance of autonomy butts up against the principle of non-maleficence: the famous dictum from the Hippocratic oath that we first do no harm.
What the nocebo effect means for informed consent is a hot topic in contemporary bioethics. Physicians have obligations to convey truthful information to promote autonomy and not to cause undue harm. To understand the debate, it’s worth taking a deeper look at what’s happening in an embodied way. How the social context is also functioning below the surface, so to speak.
A wide range of studies have investigated how context worsens a symptom. At one level, external cues, instructions or information are thought to generate [00:05:00] negative expectancies. For example, in study protocols where a local anesthetic was injected, the words used determined the pain rating. Those who were told that the injection would feel like a bee sting and a burn had consistently greater pain score than those told in positive terms that the anesthetic would numb the area of skin to make the procedure more comfortable.
In other experimental settings, a negative expectation about a particular treatment can abolish the otherwise analgesic effects of strong agents, such as opioids and nitrous oxide. An individual’s level of mistrust, apprehension, or negative expectations about a healthcare encounter are what drive the physiology of the nocebo effect.
[00:06:00] Nocebo induced pain has also been shown to be mediated by cholecystokinin signaling, a neuromodulator of pain and anxiety. When brain imaging techniques have been used to study the impact of negative verbal suggestions, it’s been shown that the psychological findings correlate to signal changes in the anterior cingulate cortex, prefrontal cortex, and insula, and that these effects are in the opposite direction of positive expectations.
Furthermore, in studies involving deception, it didn’t matter whether it was the participants receiving the drug or the physicians administering the drug who were informed that an opioid infusion would be interrupted. Just being told that the analgesic could stop was enough to lose the painkilling effect, [00:07:00] even though the drug was still being given. A loss of analgesia was associated with an increased activity in a participant’s hippocampus. Expectations and drugs operate in concert.
What this tells us is that placebo and nocebo effects are really meaning responses, expressing highly specific beliefs in bodily terms of symptoms or symptom alleviation. These beliefs and these bodily experiences are culturally as well as biologically specific. Instead of our usual way of thinking about minds as separate from our bodies or culture as distinct from nature, what we understand from placebo and nocebo effects is that we’re a complex system that is social the whole way up [00:08:00] and biological the whole way down.
The qualities of the setting, the interpersonal communication and the dynamics between physician and patient themselves produce health or healing. We have to shift toward a far more relational view of how cure and harm work in medicine. Social context shapes what happens within our bodies and how we respond to clinical care. This has implications for how we approach communication, rapport building, and ethical engagement with our patients.
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“Lessons from the Nocebo Effect”: A conversation with the artists
Eva-Marie Stern: I’m Eva Marie Stern. And I’m an art therapist and a medical educator at the University of Toronto.
Maya Morton Ninomiya: And I’m Maya Morton Ninomiya, and I am currently studying health studies at the University of Waterloo. Yeah, I think this was the first like video that I’d spent, like working with another artist on the, on the visual. I really enjoyed having someone else, especially someone like an experienced artist, like Eva Marie. After a little while, we got into a rhythm of kind of how to go back and forth effectively, and kind of work on it in chunks. And I found Eva Marie drew up sort of a storyboard. We kind of take a section and then kind of draw it out and then have a call to talk over that, to discuss it and make sure we were on the same page. And then I would sort of do my drawings, send like a draft to [00:01:00] Eva Marie, and then she could give her initial thoughts. And it was just very helpful to get input and feedback and have someone to brainstorm the concepts and the ideas, someone else who is thoroughly in the animation as well.
Eva-Marie: At the beginning of the project, it felt like work. As we got going, it felt like play. And the images that we came up with, the ideas that turned into images, would suggest the next images. The illustrations made their own magic. They just brought the story forward.
Ada Jaarsma: So the first set of questions is about your aesthetic choices. The way that you together chose to render the brain, for instance, we found spot on and also really worth reflecting on.
Eva-Marie: Well, for my part, I wanted to de emphasize the neuroanatomy, detailed science [00:02:00] aspect of the lecture. And I wanted to emphasize the human and relationship, uh, aspects of it, and Maya, so Maya and I had agreed that we would simplify the, the sketch of it, the image of it, but then Maya added these little feet on and had the brain just standing on the person’s head, which I thought was brilliant because it created this extra relationship that I hadn’t, I hadn’t conceived of, but Maya came up with.
Maya: We were talking about maybe drawing brain scans or highlighting that specific section of the brain that was affected, but thought that that would just distract from the fact that the main point we were trying to get across was that it’s expectations and drugs that are operating together.
Ada: Um, another really [00:03:00] lovely choice you made was shifting from placebos, which is a term I think most people are familiar with, to the term that is kind of my favorite, but a lot of people don’t know it, nocebos. And you had a really wonderful visual way to make that flip.
Maya: So I know we wrote, like at the beginning in the book, like had though on the one page, the placebos and then nocebos on the other and kind of did that like old vintage movie style kind of, um, filter when it went to nocebos, to kind of emphasize like the foreboding presence of nocebos.
Yeah. I remember just playing around with the, yeah, with the filters or wanting to keep the same image on the screen, but wanting to, yeah, to change moods. It’s just a quick like switch. And then suddenly it’s like, it’s the same, the same setting, but it can just flip for someone, depending on what their expectancy is.
Eva-Marie: The common feature between the [00:04:00] nocebo effect and the work that Maya and I did was our approach to it. So being open to what happens and letting the dynamics guide us to our, um, successful completion.
Maya: For me, like I sort of went into it, I didn’t know too much about placebos and nocebos going in. I think my understanding of it was the superficial, like the sugar pill and the randomized control trial and going, yeah, learning a lot more about the relational parts of it and the social parts and that there are biological impacts that you can study, but that they can originate from the social side of things as well. Not just the, what you’re ingesting.
Eva-Marie: It got me thinking a lot about a concept that’s very dear to my heart, which is how the medium is the message. [00:05:00] And I really loved, uh, Maya’s style of illustration for this project, because Maya’s style is very simple, straightforward, direct, unfussy, uh, not caught up in technicalities. And that’s exactly the message that I think the concept of placebo and the nocebo we’re trying to impart to practitioners, which is it’s not all about having the perfect technique as a professional.
It’s about being human and real and open, And, um, so I’m a big fan of Maya’s style, as part of the message that we’re trying to convey. I had a few priorities going, going into it, going into this project. One was that the, the [00:06:00] animation be, um, an instance of trauma informed education. And so that whole part where the patient is behind prison bars and gets smaller and smaller.
I was so thrilled with that part because to me it, it illustrates beautifully what it feels like to feel intimidated, scared, um, trapped and nobody else knowing it. But that’s the feeling inside. And it happens all the time in doctor’s offices, all the time, all the time. It’s invisible. And so making the invisible, visible felt like a really an ethical punch.
Another thing was, um, I was really dead set on making the practitioner and the patient interchangeable, that they be, [00:07:00] um, visually interchangeable beneath their clothes, like beneath the cultural getup, beneath the roles that we’re all, um, we’re all, both: we can all be both. We can be patient, and we can be practitioner; at a moment’s notice it can switch.
And so the whole idea that the placebo effect or the nocebo effect only happens to certain people who are particularly vulnerable to these things: throw that out, and make sure that we convey the message that we all, we all experience, uh, relationships and interactions in these profoundly personal ways that are indubitably linked to our histories and our expectations.
That was really important. And I feel like we totally nailed it at the end, [00:08:00] right, Maya? When at the very end, where we have the social all the way up and biological all the way down. And it’s the relationship that matters. That, when we had, when we’d figured that one out, I was happy with the whole thing.
Maya: yeah. I remember asking you and yes, discussing them looking as similar as possible and just the, the doctor’s outfit and the patient’s clothing looking different. And especially in this scene where they both are blindfolded. Yeah. Both the doctor and the patient, not knowing, um, What the treatment is, um, them looking so similar and being blindfolded by the same blindfold, um, being struck by the same lightning.
Eva-Marie: Yeah. We’re all in this together. We’re all the same, under our clothes, we’re all the same. Under our degrees, we’re all the same. I love how the way you convey something is at least as important as [00:09:00] the, what you convey.