• Ethics- Medical

I am grateful for the variety of feedback. Three themes struck me: first, commentators recognised the value of open notes but underlined the importance of exploring unintended consequences of the innovation particularly for already disadvantaged populations; second, they suggested nocebo effects might arise via additional routes not identified in my paper; third, they signalled the need for further empirical and ethical exploration of nocebo effects.

Exploring all three issues and offering a commentary that was equal parts intriguing and perturbing, Chang and Torous proposed nocebo effects and other harms might be ubiquitous in the digital health space.1 For example, they hypothesised that the preoccupation with checking health tracking data including adverse readings or outcomes available via downloadable apps and wearable devices might induce nocebo effects. This supposition is worthy of further scrutiny. Chang and Torous also highlighted the lack of research into potentially disparate effects of digital health innovations on different populations. Their point is well-taken. Similar to limitations with research in placebo studies, researchers need to work harder to learn more about the uptake, use and impact of digital health innovations among diverse populations.

Kharko and Hägglund2 proposed patients with medically unexplained symptoms (MUS) may also be at risk of nocebo effects since they are more likely to distrust clinicians, and are vulnerable to communication breakdowns in appointments. Indeed, physician surveys suggest people with MUS may be at increased risk of placebo-prescribing,3 4 and in this journal I previously suggested open notes might be a vehicle that reduces deceptive practices.5 As Kharko …