What if the Placebo Effect Isn’t a Trick?
New research is zeroing in on a biochemical
basis for the placebo effect — possibly opening a Pandora’s box for Western
medicine.
Nov. 7, 2018
[[The important lesson: the obvious fact that the placebo effect really helps people was missed for 200+ years.]]
Photo
illustration by Paul Sahre
The Chain of
Office of the Dutch city of Leiden is a broad and colorful ceremonial necklace
that, draped around the shoulders of Mayor Henri Lenferink, lends a magisterial
air to official proceedings in this ancient university town. But whatever gravitas
it provided Lenferink as he welcomed a group of researchers to his city, he was
quick to undercut it. “I am just a humble historian,” he told the 300 members
of the Society for Interdisciplinary Placebo Studies who had gathered in
Leiden’s ornate municipal concert hall, “so I don’t know anything about your
topic.” He was being a little disingenuous. He knew enough about the topic that
these psychologists and neuroscientists and physicians and anthropologists and
philosophers had come to his city to talk about — the placebo effect, the
phenomenon whereby suffering people get better from treatments that have no
discernible reason to work — to call it “fake medicine,” and to add that it
probably works because “people like to be cheated.” He took a beat. “But in the
end, I believe that honesty will prevail.”
Lenferink might
not have been so glib had he attended the previous day’s meeting on the other
side of town, at which two dozen of the leading lights of placebo science spent
a preconference day agonizing over their reputation — as purveyors of sham
medicine who prey on the desperate and, if they are lucky, fool people into
feeling better — and strategizing about how to improve it. It’s an urgent
subject for them, and only in part because, like all apostate professionals,
they crave mainstream acceptance. More important, they are motivated by a
conviction that the placebo is a powerful medical treatment that is ignored by
doctors only at their patients’ expense.
And after a
quarter-century of hard work, they have abundant evidence to prove it. Give
people a sugar pill, they have shown, and those patients — especially if they
have one of the chronic, stress-related conditions that register the strongest
placebo effects and if the treatment is delivered by someone in whom they have
confidence — will improve. Tell someone a normal milkshake is a diet beverage,
and his gut will respond as if the drink were low fat. Take athletes to the top
of the Alps, put them on exercise machines and hook them to an oxygen tank, and
they will perform better than when they are breathing room air — even if room
air is all that’s in the tank. Wake a patient from surgery and tell him you’ve
done an arthroscopic repair, and his knee gets better even if all you did was
knock him out and put a couple of incisions in his skin. Give a drug a fancy
name, and it works better than if you don’t.
You don’t even
have to deceive the patients. You can hand a patient with irritable bowel
syndrome a sugar pill, identify it as such and tell her that sugar pills are
known to be effective when used as placebos, and she will get better,
especially if you take the time to deliver that message with warmth and close
attention. Depression, back pain, chemotherapy-related malaise, migraine,
post-traumatic stress disorder: The list of conditions that respond to placebos
— as well as they do to drugs, with some patients — is long and growing.
But as
ubiquitous as the phenomenon is, and as plentiful the studies that demonstrate
it, the placebo effect has yet to become part of the doctor’s standard
armamentarium — and not only because it has a reputation as “fake medicine”
doled out by the unscrupulous to the credulous. It also has, so far, resisted a
full understanding, its mechanisms shrouded in mystery. Without a clear
knowledge of how it works, doctors can’t know when to deploy it, or how.
Not that the
researchers are without explanations. But most of these have traditionally been
psychological in nature, focusing on mechanisms like expectancy — the set of beliefs
that a person brings into treatment — and the kind of conditioning that Ivan
Pavlov first described more than a century ago. These theories, which posit
that the mind acts upon the body to bring about physical responses, tend to
strike doctors and researchers steeped in the scientific tradition as
insufficiently scientific to lend credibility to the placebo effect. “What
makes our research believable to doctors?” asks Ted Kaptchuk, head of Harvard
Medical School’s Program in Placebo Studies and the Therapeutic Encounter.
“It’s the molecules. They love that stuff.” As of now, there are no molecules
for conditioning or expectancy — or, indeed, for Kaptchuk’s own pet theory,
which holds that the placebo effect is a result of the complex conscious and nonconscious
processes embedded in the practitioner-patient relationship — and without them,
placebo researchers are hard-pressed to gain purchase in mainstream medicine.
But as many of
the talks at the conference indicated, this might be about to change. Aided by
functional magnetic resonance imaging (f.M.R.I.) and other precise surveillance
techniques, Kaptchuk and his colleagues have begun to elucidate an ensemble of
biochemical processes that may finally account for how placebos work and why
they are more effective for some people, and some disorders, than others. The
molecules, in other words, appear to be emerging. And their emergence may
reveal fundamental flaws in the way we understand the body’s healing
mechanisms, and the way we evaluate whether more standard medical interventions
in those processes work, or don’t. Long a useful foil for medical science, the
placebo effect might soon represent a more fundamental challenge to it.
In a way, the placebo effect owes its poor
reputation to the same man who cast aspersions on going to bed late and
sleeping in. Benjamin Franklin was, in 1784, the ambassador of the fledgling
United States to King Louis XVI’s court. Also in Paris at the time was a
Viennese physician named Franz Anton Mesmer. Mesmer fled Vienna a few years
earlier when the local medical establishment determined that his claim to have
cured a young woman’s blindness by putting her into a trance was false, and
that, even worse, there was something unseemly about his relationship with her.
By the time he arrived in Paris and hung out his shingle, Mesmer had acquired
what he lacked in Vienna: a theory to account for his ability to use trance
states to heal people. There was, he claimed, a force pervading the universe
called animal magnetism that could cause illness when perturbed. Conveniently
enough for Mesmer, the magnetism could be perceived and de-perturbed only by
him and people he had trained.
Mesmer’s method
was strange, even in a day when doctors routinely prescribed bloodletting and
poison to cure the common cold. A group of people complaining of maladies like
fatigue, numbness, paralysis and chronic pain would gather in his office, take
seats around an oak cask filled with water and grab on to metal rods immersed
in the water. Mesmer would alternately chant, play a glass harmonium and wave
his hands at the afflicted patients, who would twitch and cry out and sometimes
even lose consciousness, whereupon they would be carried to a recovery room.
Enough people reported good results that patients were continually lined up at
Mesmer’s door waiting for the next session.
It was the kind
of success likely to arouse envy among doctors, but more was at stake than
professional turf. Mesmer’s claim that a force existed that could only be
perceived and manipulated by the elect few was a direct challenge to an idea
central to the Enlightenment: that the truth could be determined by anyone with
senses informed by skepticism, that Scripture could be supplanted by facts and
priests by a democracy of people who possessed them. So, when the complaints
about Mesmer came to Louis, it was to the scientists that the king — at pains
to show himself an enlightened man — turned. He appointed, among others,
Lavoisier the chemist, Bailly the astronomer and Guillotin the physician to
investigate Mesmer’s claims, and he installed Franklin at the head of their
commission.
To the Franklin
commission, the question wasn’t whether Mesmer was a fraud and his patients
were dupes. Everyone could be acting in good faith, but belief alone did not
prove that the magnetism was at work. To settle this question, they designed a
series of trials that ruled out possible causes of the observed effects other
than animal magnetism. The most likely confounding variable, they thought, was
some faculty of mind that made people behave as they did under Mesmer’s
ministrations. To rule this out, the panel settled upon a simple method: a
blindfold. Over a period of a few months, they ran a series of experiments that
tested whether people experienced the effects of animal magnetism even when
they couldn’t see.
One of Mesmer’s
disciples, Charles d’Eslon, conducted the tests. The panel instructed him to
wave his hands at a part of a patient’s body, and then asked the patient where
the effect was felt. They took him to a copse to magnetize a tree — Mesmer
claimed that a patient could be treated by touching one — and then asked the
patient to find it. They told patients d’Eslon was in the room when he was not,
and vice versa, or that he was doing something that he was not. In trial after
trial, the patients responded as if the doctor were doing what they thought he
was doing, not what he was actually doing.
It was possibly
the first-ever blinded experiment, and it soundly proved what scientists today
call the null hypothesis: There was no causal connection between the behavior
of the doctor and the response of the patients, which meant, as Franklin’s
panel put it in their report, that “this agent, this fluid, has no existence.”
That didn’t imply that people were pretending to twitch or cry
out, or lying when they said they felt better; only that their behavior wasn’t
a result of this nonexistent force. Rather, the panel wrote, “the imagination
singly produces all the effects attributed to the magnetism.”
When the panel
gave d’Eslon a preview of its findings, he took it with equanimity. Given the
results of the treatment (as opposed to the experiment), he opined, the
imagination, “directed to the relief of suffering humanity, would be a most
valuable means in the hands of the medical profession” — a subject to which
these august scientists might wish to apply their methods. But events
intervened. Franklin was called back to America in 1785; Louis XVI had bigger
trouble on his hands and, along with Lavoisier and Bailly, eventually met with
the short, sharp shock of the device named for Guillotin.
The panel’s
report was soon translated into English by William Godwin, the father of Mary
Shelley. The story spread fast — not because of the healing potential that
d’Eslon had suggested, but because of the implications for science as a whole.
The panel had demonstrated that by putting imagination out of play, science
could find the truth about our suffering bodies, in the same way it had found
the truth about heavenly bodies. Hiving off subjectivity from the rest of
medical practice, the Franklin commission had laid the conceptual foundation
for the brilliant discoveries of modern medicine, the antibiotics and vaccines
and other drugs that can be dispensed by whoever happens to possess the
prescription pad, and to whoever happens to have the disease. Without meaning
to, they had created an epistemology for the healing arts — and, in the
process, inadvertently conjured the placebo effect, and established it as that
to which doctors must remain blind.
Photo
illustration by Paul Sahre
It wouldn’t be
the last time science would turn its focus to the placebo effect only to
quarantine it. At a 1955 meeting of the American Medical Association, the
Harvard surgeon Henry Beecher pointed out to his colleagues that while they
might have thought that placebos were fake medicine — even the name, which
means “I shall please” in Latin, carries more than a hint of contempt — they
couldn’t deny that the results were real. Beecher had been looking at the
subject systematically, and he determined that placebos could relieve anxiety
and postoperative pain, change the blood chemistry of patients in a way similar
to drugs and even cause side effects. In general, he told them, more than
one-third of patients would get better when given a treatment that was,
pharmacologically speaking, inert.
If the placebo
was as powerful as Beecher said, and if doctors wanted to know whether their
drugs actually worked, it was not sufficient simply to give patients the drugs
and see whether they did better than patients who didn’t interact with the
doctor at all. Instead, researchers needed to assume that the placebo effect
was part of every drug effect, and that drugs could be said to work only to the
extent that they worked better than placebos. An accurate measure of drug
efficacy would require comparing the response of patients taking it with that
of patients taking placebos; the drug effect could then be calculated by
subtracting the placebo response from the overall response, much as a
deli-counter worker subtracts the weight of the container to determine how much
lobster salad you’re getting.
In the last
half of the 1950s, this calculus gave rise to a new way to evaluate drugs: the
double-blind, placebo-controlled clinical trial, in which neither patient nor
clinician knew who was getting the active drug and who the placebo. In 1962,
when the Food and Drug Administration began to require pharmaceutical companies
to prove their new drugs were effective before they came to market, they
increasingly turned to the new method; today, virtually every prospective new
drug has to outperform placebos on two independent studies in order to gain
F.D.A. approval.
Like Franklin’s
commission, the F.D.A. had determined that the only way to sort out the real
from the fake in medicine was to isolate the imagination. It also echoed the
royal panel by taking note of the placebo effect only long enough to dismiss
it, giving it a strange dual nature: It’s included in clinical trials because
it is recognized as an important part of every treatment, but it is treated as
if it were not important in itself. As a result, although virtually every
clinical trial is a study of the placebo effect, it remains underexplored — an
outcome that reflects the fact that there is no money in sugar pills and thus
no industry interest in the topic as anything other than a hurdle it needs to
overcome.
When Ted
Kaptchuk was asked
to give the opening keynote address at the conference in Leiden, he
contemplated committing the gravest heresy imaginable: kicking off the
inaugural gathering of the Society for Interdisciplinary Placebo Studies by
declaring that there was no such thing as the placebo effect. When he broached
this provocation in conversation with me not long before the conference, it
became clear that his point harked directly back to Franklin: that the topic he
and his colleagues studied was created by the scientific establishment, and
only in order to exclude it — which means that they are always playing on
hostile terrain. Science is “designed to get rid of the husks and find the
kernels,” he told me. Much can be lost in the threshing — in particular,
Kaptchuk sometimes worries, the rituals embedded in the doctor-patient
encounter that he thinks are fundamental to the placebo effect, and that he
believes embody an aspect of medicine that has disappeared as scientists and
doctors pursue the course laid by Franklin’s commission. “Medical care is a
moral act,” he says, in which a suffering person puts his or her fate in the
hands of a trusted healer.
“I don’t love
science,” Kaptchuk told me. “I want to know what heals people.” Science may not
be the only way to understand illness and healing, but it is the established
way. “That’s where the power is,” Kaptchuk says. That instinct is why he left
his position as director of a pain clinic in 1990 to join Harvard — and it’s
why he was delighted when, in 2010, he was contacted by Kathryn Hall, a
molecular biologist. Here was someone with an interest in his topic who was
also an expert in molecules, and who might serve as an emissary to help usher
the placebo into the medical establishment.
Hall’s own
journey into placebo studies began 15 years before her meeting with Kaptchuk,
when she developed a bad case of carpal tunnel syndrome. Wearing a wrist brace
didn’t help, and neither did over-the-counter drugs or the codeine her doctor
prescribed. When a friend suggested she visit an acupuncturist, Hall balked at
the idea of such an unscientific approach. But faced with the alternative,
surgery, she decided to make an appointment. “I was there for maybe 10 minutes,”
she recalls, “when she stuck a needle here” — Hall points to a spot on her
forearm — “and this awful pain just shot through my arm.” But then the pain
receded and her symptoms disappeared, as if they had been carried away on the
tide. She received a few more treatments, during which the acupuncturist taught
her how to manipulate a spot near her elbow if the pain recurred. Hall needed
the fix from time to time, but the problem mostly just went away.
“I couldn’t
believe it,” she told me. “Two years of gross drugs, and then just one
treatment.” All these years later, she’s still wonder-struck. “What was that?”
she asks. “Rub the spot, and the pain just goes away?”
Hall was
working for a drug company at the time, but she soon left to get a master’s
degree in visual arts, after which she started a documentary-production
company. She was telling her carpal-tunnel story to a friend one day and
recounted how the acupuncturist had climbed up on the table with her. (“I was
like, ‘Oh, my God, what is this woman doing?’ ” she told me. “It was very
dramatic.”) She’d never been able to understand how the treatment worked, and
this memory led her to wonder out loud if maybe the drama itself had something
to do with the outcome.
Her friend
suggested she might find some answers in Ted Kaptchuk’s work. She picked up his
book about Chinese medicine, “The Web that Has No Weaver,” in which he
mentioned the possibility that placebo effects figure strongly in acupuncture,
and then she read a study he had conducted that put that question to the test.
Kaptchuk had
divided people with irritable bowel syndrome into three groups. In one,
acupuncturists went through all the motions of treatment, but used a device
that only appeared to insert a needle. Subjects in a second group also got sham
acupuncture, but delivered with more elaborate doctor-patient interaction than
the first group received. A third group was given no treatment at all. At the
end of the trial, both treatment groups improved more than the no-treatment
group, and the “high interaction” group did best of all.
Kaptchuk, who
before joining Harvard had been an acupuncturist in private practice, wasn’t
particularly disturbed by the finding that his own profession worked even when
needles were not actually inserted; he’d never thought that placebo treatments
were fake medicine. He was more interested in how the strength of the treatment
varied with the quality and quantity of interaction between the healer and the
patient — the drama, in other words. Hall reached out to him shortly after she
read the paper.
The findings of
the I.B.S. study were in keeping with a hypothesis Kaptchuk had formed over the
years: that the placebo effect is a biological response to an act of caring;
that somehow the encounter itself calls forth healing and that the more intense
and focused it is, the more healing it evokes. He elaborated on this idea in a
comparative study of conventional medicine, acupuncture and Navajo “chantway
rituals,” in which healers lead storytelling ceremonies for the sick. He argued
that all three approaches unfold in a space set aside for the purpose and
proceed as if according to a script, with prescribed roles for every
participant. Each modality, in other words, is its own kind of ritual, and
Kaptchuk suggested that the ritual itself is part of what makes the procedure
effective, as if the combined experiences of the healer and the patient,
reinforced by the special-but-familiar surroundings, evoke a healing response
that operates independently of the treatment’s specifics. “Rituals trigger
specific neurobiological pathways that specifically modulate bodily sensations,
symptoms and emotions,” he wrote. “It seems that if the mind can be persuaded,
the body can sometimes act accordingly.” He ended that paper with a call for further
scientific study of the nexus between ritual and healing.
When Hall
contacted him, she seemed like a perfect addition to the team he was assembling
to do just that. He even had an idea of exactly how she could help. In the
course of conducting the study, Kaptchuk had taken DNA samples from subjects in
hopes of finding some molecular pattern among the responses. This was an
investigation tailor-made to Hall’s expertise, and she agreed to take it on. Of
course, the genome is vast, and it was hard to know where to begin — until, she
says, she and Kaptchuk attended a talk in which a colleague presented evidence
that an enzyme called COMT affected people’s response to pain and painkillers.
Levels of that enzyme, Hall already knew, were also correlated with Parkinson’s
disease, depression and schizophrenia, and in clinical trials people with those
conditions had shown a strong placebo response. When they heard that COMT was
also correlated with pain response — another area with significant placebo
effects — Hall recalls, “Ted and I looked at each other and were like: ‘That’s
it! That’s it!’ ”
It is not
possible to assay levels of COMT directly in a living brain, but there is a
snippet of the genome called rs4680 that governs the production of the enzyme,
and that varies from one person to another: One variant predicts low levels of
COMT, while another predicts high levels. When Hall analyzed the I.B.S.
patients’ DNA, she found a distinct trend. Those with the high-COMT variant had
the weakest placebo responses, and those with the opposite variant had the
strongest. These effects were compounded by the amount of interaction each
patient got: For instance, low-COMT, high-interaction patients fared best of
all, but the low-COMT subjects who were placed in the no-treatment group
did worse than the other genotypes in that group. They were,
in other words, more sensitive to the impact of the relationship with the
healer.
The discovery
of this genetic correlation to placebo response set Hall off on a continuing
effort to identify the biochemical ensemble she calls the placebome — the term
reflecting her belief that it will one day take its place among the other
important “-omes” of medical science, from the genome to the microbiome. The
rs4680 gene snippet is one of a group that governs the production of COMT, and
COMT is one of a number of enzymes that determine levels of catecholamines, a
group of brain chemicals that includes dopamine and epinephrine. (Low COMT
tends to mean higher levels of dopamine, and vice versa.) Hall points out that
the catecholamines are associated with stress, as well as with reward and good
feeling, which bolsters the possibility that the placebome plays an important
role in illness and health, especially in the chronic, stress-related conditions
that are most susceptible to placebo effects.
Photo
illustration by Paul Sahre
Her findings
take their place among other results from neuroscientists that strengthen the
placebo’s claim to a place at the medical table, in particular studies using
f.M.R.I. machines that have found consistent patterns of brain activation in
placebo responders. “For years, we thought of the placebo effect as the work of
imagination,” Hall says. “Now through imaging you can literally see the brain
lighting up when you give someone a sugar pill.”
One group with a particularly keen interest in those
brain images, as Hall well knows, is her former employers in the pharmaceutical
industry. The placebo effect has been plaguing their business for more than a
half-century — since the placebo-controlled study became the clinical-trial
gold standard, requiring a new drug to demonstrate a significant therapeutic
benefit over placebo to gain F.D.A. approval.
That’s a bar
that is becoming ever more difficult to surmount, because the placebo effect
seems to be becoming stronger as time goes on. A 2015 study published in the
journal Pain analyzed 84 clinical trials of pain medication conducted between
1990 and 2013 and found that in some cases the efficacy of placebo had grown
sharply, narrowing the gap with the drugs’ effect from 27 percent on average to
just 9 percent. The only studies in which this increase was detected were
conducted in the United States, which has spawned a variety of theories to
explain the phenomenon: that patients in the United States, one of only two
countries where medications are allowed to be marketed directly to consumers,
have been conditioned to expect greater benefit from drugs; or that the larger
and longer-duration trials more common in America have led to their often being
farmed out to contract organizations whose nurses’ only job is to conduct the
trial, perhaps fostering a more placebo-triggering therapeutic interaction.
Whatever the
reason, a result is that drugs that pass the first couple of stages of the
F.D.A. approval process founder more and more frequently in the larger
late-stage trials; more than 90 percent of pain medications now fail at this
stage. The industry would be delighted if it were able to identify placebo
responders — say, by their genome — and exclude them from clinical trials.
That may seem
like putting a thumb on the scale for drugs, but under the logic of the
drug-approval regime, to eliminate placebo effects is not to cheat; it merely
reduces the noise in order for the drug’s signal to be heard more clearly. That
simple logic, however, may not hold up as Hall continues her research into the
genetic basis of the placebo. Indeed, that research may have deeper
implications for clinical drug trials, and for the drugs themselves, than pharma
companies might expect.
Since 2013,
Hall has been involved with the Women’s Health Study, which has tracked the
cardiovascular health of nearly 40,000 women over more than 20 years. The
subjects were randomly divided into four groups, following standard
clinical-trial protocol, and received a daily dose of either vitamin E,
aspirin, vitamin E with aspirin or a placebo. A subset also had their DNA
sampled — which, Hall realized, offered her a vastly larger genetic database to
plumb for markers correlated to placebo response. Analyzing the data amassed
during the first 10 years of the study, Hall found that the women with the
low-COMT gene variant had significantly higher rates of heart disease than
women with the high-COMT variant, and that the risk was reduced for those
low-COMT women who received the active treatments but not in those given
placebos. Among high-COMT people, the results were the inverse: Women taking
placebos had the lowest rates of disease; people in the treatment arms had an
increased risk.
These findings
in some ways seem to confound the results of the I.B.S. study, in which it was
the low-COMT patients who benefited most from the placebo. But, Hall argues,
what’s important isn’t the direction of the effect, but rather that there is an
effect, one that varies depending on genotype — and that the same gene variant
also seems to determine the relative effectiveness of the drug. This outcome
contradicts the logic underlying clinical trials. It suggests that placebo and
drug do not involve separate processes, one psychological and the other
physical, that add up to the overall effectiveness of the treatment; rather,
they may both operate on the same biochemical pathway — the one governed in
part by the COMT gene.
Hall has begun
to think that the placebome will wind up essentially being a chemical pathway
along which healing signals travel — and not only to the mind, as an experience
of feeling better, but also to the body. This pathway may be where the brain
translates the act of caring into physical healing, turning on the biological
processes that relieve pain, reduce inflammation and promote health, especially
in chronic and stress-related illnesses — like irritable bowel syndrome and
some heart diseases. If the brain employs this same pathway in response to
drugs and placebos, then of course it is possible that they might work
together, like convoys of drafting trucks, to traverse the territory. But it is
also possible that they will encroach on one another, that there will be
traffic jams in the pathway.
What if, Hall
wonders, a treatment fails to work not because the drug and the individual are
biochemically incompatible, but rather because in some people the drug
interferes with the placebo response, which if properly used might reduce disease?
Or conversely, what if the placebo response is, in people with a different
variant, working against drug treatments, which would mean that a change in the
psychosocial context could make the drug more effective? Everyone may respond
to the clinical setting, but there is no reason to think that the response is
always positive. According to Hall’s new way of thinking, the placebo effect is
not just some constant to be subtracted from the drug effect but an intrinsic
part of a complex interaction among genes, drugs and mind. And if she’s right,
then one of the cornerstones of modern medicine — the placebo-controlled
clinical trial — is deeply flawed.
When Kathryn
Hall told Ted
Kaptchuk what she was finding as she explored the relationship of COMT to the
placebo response, he was galvanized. “Get this molecule on the map!” he urged
her. It’s not hard to understand his excitement. More than two centuries after
d’Eslon suggested that scientists turn their attention directly to the placebo
effect, she did exactly that and came up with a finding that might have
persuaded even Ben Franklin.
But Kaptchuk
also has a deeper unease about Hall’s discovery. The placebo effect can’t be
totally reduced to its molecules, he feels certain — and while research like
Hall’s will surely enhance its credibility, he also sees a risk in playing his
game on scientific turf. “Once you start measuring the placebo effect in a
quantitative way,” he says, “you’re transforming it to be something other than
what it is. You suck out what was previously there and turn it into science.”
Reduced to its molecules, he fears, the placebo effect may become “yet another
thing on the conveyor belt of routinized care.”
“We’re dancing with the devil here,” Kaptchuk once told me, by
way of demonstrating that he was aware of the risks he’s taking in using
science to investigate a phenomenon it defined only to exclude. Kaptchuk, an
observant Jew who is a student of both the Torah and the Talmud, later modified
his comment. It’s more like Jacob wrestling with the angel, he said — a battle
that Jacob won, but only at the expense of a hip injury that left him lame for
the rest of his life.
Indeed, Kaptchuk seems wounded when he complains about the
pervasiveness of research that uses healthy volunteers in academic settings, as
if the response to mild pain inflicted on an undergraduate participating in an
on-campus experiment is somehow comparable to the despair often suffered by
people with chronic, intractable pain. He becomes annoyed when he talks about
how quickly some of his colleagues want to move from these studies to clinical
recommendations. And he can even be disparaging of his own work, wondering, for
instance, whether the study in which placebos were openly given to irritable
bowel syndrome patients succeeded only because it convinced the subjects that
the sugar was really a drug. But it’s the prospect of what will become of his
findings, and of the placebo, as they make their way into clinical practice,
that really seems to torment him.
Kaptchuk may wish “to help reconfigure biomedicine by rejecting
the idea that healing is only the application of mechanical tools.” He may
believe that healing is a moral act in which “caring in the context of hope
qualitatively changes clinical outcomes.” He may be convinced that the
relationship kindled by the encounter between a suffering person and a healer
is a central, and almost entirely overlooked, component of medical treatment.
And he may have dedicated the last 20 years of his life to persuading the
medical establishment to listen to him. But he may also come to regret the
outcome.
After all, if Hall is right that clinician warmth is especially
effective with a certain genotype, then, as she wrote in the paper presenting
her findings from the I.B.S./sham-acupuncture study, it is also true that a
different group will “derive minimum benefit” from “empathic attentions.”
Should medical rituals be doled out according to genotype, with warmth and
caring withheld in order to clear the way for the drugs? And if she is correct
that a certain ensemble of neurochemical events underlies the placebo effect,
then what is to stop a drug company from manufacturing a drug — a real drug,
that is — that activates the same process pharmacologically? Welcomed back into
the medical fold, the placebo effect may raise enough mischief to make Kaptchuk
rue its return, and bewilder patients when they discover that their doctor’s
bedside manner is tailored to their genes.
For the most part, most days, Kaptchuk manages to keep his
qualms to himself, to carry on as if he were fully confident that scientific
inquiry can restore the moral dimension to medicine. But the precariousness of
his endeavors is never far from his mind. “Will this work destroy the stuff
that actually has to do with wisdom, preciousness, imagination, the things that
are actually critical to who we are as human beings?” he asks. His answer: “I
don’t know, but I have to believe there is an infinite reserve of wisdom and
imagination that will resist being reduced to simple materialistic
explanations.”
The ability to hold two contradictory thoughts in mind at the
same time seems to come naturally to Kaptchuk, but he may overestimate its
prevalence in the rest of us. Even if his optimism is well placed, however,
there’s nothing like being sick to make a person toss that kind of intelligence
aside in favor of the certainties offered by modern medicine. Indeed, it’s
exactly that yearning that sickness seems to awaken and that our healers,
imbued with the power of science, purport to provide, no imagination required.
Armed with our confidence in them, we’re pleased to give ourselves over to
their ministrations, and pleased to believe that it’s the molecules, and the
molecules alone, that are healing us. People do like to be cheated, after all.
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