The Paradoxical Placebo Effect: An Ethical Dilemma or the Essence of Healing?

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The Paradoxical Placebo Effect:  An Ethical Dilemma or the Essence of Healing?

            Ask the average person on the street what he thinks of the placebo effect, and it's likely that he will not be able to give a coherent answer. This is not because people are stupid, but because what, exactly, the placebo effect is remains shrouded in mystery.  Much of the mainstream medical community has, in fact, done its best to keep people in the dark about the significance of the placebo effect. Most published literature is descriptive of the subject in a profoundly derogatory sense. But its power is indeed great, and may, in fact, be the very essence of the healing process.

            Placebo is derived from the Latin words that mean, "to please." It is apparent that this is not a misnomer. The name is derived from the observation that the patient longs to please the doctor, and vice-versa, and that this in fact can have real consequences. The word has a dual meaning in modern medicine. In orthodox clinical medicine, it signifies a substance that contains no medication, administered for its psychological effect.  In the world of experimental medicine, also known as clinical trials, it refers to an inactive substance used as a control in a study. The "placebo effect" is, of course, the demonstrable result on human subjects of using a placebo, in both settings. Whether or not it is appropriate to use placebos in either setting is a matter that will shortly be addressed.

            Is the placebo actually an inert, totally useless substance, or not? In researching the placebo effect, one comes across a great deal of contradictory information. It is difficult to know what, or whom, to believe. First of all, there are scientists and researchers of some reputation who state that the use of placebos in any milieu is tantamount to quackery, as their effects are nil and involve real deception on the part of the medical professional (British Medical Journal).  Placebos are commonly believed to have neither actual effects nor scientific basis, and perhaps the credulous, unsophisticated, masses with only a high-school education in science need to be protected from quacks and charlatans and told what they should believe.  Scientists such as Carl Sagan and Robert Park are in agreement about this subject. To them, science is a light in the darkness, and the discovery of modern scientific principles are the protection the public has so desperately needed. To them, the scientific method should not be questioned; doing so exposes a person to the worst dangers and therefore one must listen to experts such as themselves expound upon the subject.

            It is necessary to examine their point of view, and to dissect it carefully in order to uncover its fallacies. This is not so simple, as their failing is one of perspective, emphasis and interpretation of what scientific enquiry really consists of.  The question one needs to ask first of all is whether science is indeed a light in the darkness, or if it is merely one way of examining the world.

            Park and Sagan acknowledge that new ideas should be considered, but that science is self-correcting enough so that the field is absolutely kept on track. Science is "evidence-based." Therefore ideas that do not show enough evidence will eventually to be discarded, and this is as things should be. Park and Sagan assert that science is truly an objective way of gathering evidence about how the world really is. Competent researchers only use anecdotal evidence to suggest new hypotheses and new studies, but never to support them. They are convinced that reports of personal experiences can lack accuracy, be biased, or even completely false. Therefore when a new theory is proposed, it needs to be studied repeatedly until experiments prove it to be true or false. Mistaken notions need to be disproved, and this can be done through the use of science, for the good of all mankind, apparently (Park, Sagan).           

            Richard Feynman, the Nobel laureate, wrote eloquently about what science really is, and what it is not, in "The Meaning of it All: Thoughts of a Citizen-Scientist." His attitude was different; he attempted to define the term in a manner easily understandable to the layman. "Science" is the word used for a special method of discovering things about the world and it is also the body of knowledge comprising the things we have found out through the use of this method. It is also used to indicate the new things you can do when you have discovered something previously unknown. In this last case, science and technology are often used interchangeably. The process of scientific experimentation can vary from experiment to experiment, but all of them have in common the effort to be extremely objective and accurate in measurement, and in making observations. Feynman made it clear, however, that the body of scientific knowledge at any time in history is fraught with uncertainty. There are varying degrees of uncertainty, and some ideas or theories seem to be proven absolutely. There is, however, virtually nothing in science that we are absolutely, unequivocally, certain of.  The ancients described the world in a poetic, imaginative way as an elephant standing on the back of a tortoise, swimming in an endless sea. According to Feynman, modern scientists are no more capable of understanding the infinity of space than they were in the past. In addition to his references to the limitations of science, Feynman asserted that the things that cannot be studied through the scientific method are by no means valueless or inconsequential. His impression of nature was that it "had a much greater imagination than the imagination of man." And it was likely that we hadn't gotten it right in dreaming up theories, not by a long shot (Feynman).  These are extremely radical statements. Feynman's attitude was most unusual, even precious, as professionals of his stature all too often seek to obfuscate, rather than explain, in order to reinforce their authority.

            Lewis Thomas, head of Memorial Sloan-Kettering and a gifted writer, sat squarely between the two camps in his opinions about the veracity of science and the wonders of the natural world. Thomas, a physician and the son of a family practitioner, welcomed the advent of scientific medicine with great enthusiasm. However, in his essay, "To Err Is Human," he stated that mistakes are wonderful opportunities to test new ideas, and to change one's perspective. Mistakes are a serendipitous blessing. Mistakes are the way people learn, and openness to new ideas is of paramount importance (Thomas, Medusa 36-40). One can infer something of great value from these two luminaries. Perhaps we make mistakes in describing the world, but that does not make all of our observations invalid. Sometimes an idea has merit, but we don't yet have enough information to be able to test it properly. New information may at any time be found in support of a formerly questionable theory. This concept is also a cornerstone of the placebo effect, since it an observable phenomenon which no one, at this point, can explain absolutely.                                                                                                                              

            Common sense dictates that one should educate his or herself as much as possible about the placebo effect, and the history of its significance in medicine. It's also a good idea to learn about the history of medicine in general, to improve the chances that a sound judgment about the subject can be made. Modern medicine likes to deny its roots in the past; it would be equally fallacious to deny the historical development of science and the evolution of medicine. Learning about the historical underpinnings of medicine may seem at first to be an insurmountable task, akin to the labors of Hercules, and who really has the time, anyway?  The effort in this case is well worth the time expended. It is not possible to describe every significant medical discovery or personality worldwide, but studying the history of western medicine, at least, brings to light many surprises.

            Science and technology are certainly the basis of modern medicine, but this was not always the case. The scientific method was not always used, and was long in development, but valid discoveries were made in medicine nonetheless, and therapeutic treatments were very often quite effective. Medicine as a body of knowledge was arrived at mostly through trial and error. This seems inconceivable in light of the present-day fixation on medical technology and, ostensibly, the importance of the scientific method.  For a long time I shared this selfsame fixation. Some twenty years ago, I was briefly acquainted with an organic chemist, section head for one of the large pharmaceutical companies in the Princeton, NJ area. He was Yugoslavian, and had immigrated to the USA long ago but retained an essentially European, open-minded attitude about herbalism. This man, who I will call Z, was developing for his employer a laboratory-derived medication which hopefully would mitigate the harmful vascular effects of diabetes. In his spare time he had recently completed research into the possible antimicrobial activity of garlic, and verified its effectiveness. I was amazed, and, quite frankly, skeptical. Garlic, I knew, was part of European, Chinese, and Indian herbal lore. I wondered how ancient civilizations could possibly have determined anything therapeutically significant before the development of the scientific method, which was only about 50 years old. I was told, with great amusement, that thousands of years of trial and error were at least as accurate as the scientific method. I learned a valuable lesson that day, which I was never to forget.  It is, of course absolutely necessary to change perspective if what is observed does not fit neatly into one's preconceived notions of how the world works.

            Ancient Indian, or Hindu medicine, dates back at least 6,000 years. Based on celestial personalities, it was described in the oldest known Indian text, the Rig Veda. Diseases at that point were attributed to evil spirits or the wrath of gods. The therapeutic system, which consisted both of spiritual practices and herbal medications, was called Ayurveda, or "the science of life." Ayurveda is in fact still practiced in India.  A general belief exists, even among medical authorities, that an integration of antique and modern medical techniques is not only socially prudent, but also most effective. Egyptian medicine is also very ancient, dating back to 3,000 BC, or even earlier. Imhotep, a renowned architect, astronomer, and later a physician, was in fact the first known physician in recorded history. On his death, he was elevated to demigod status. The names of other Egyptian physicians are known to us as deities: Isis, Thoth, and Horus. It is likely that they were real individuals who were considered divine because of their great knowledge and ability as healers.  Egyptian medicine lent its stamp to modern medicine, as the Rx symbol derived from the eye of Horus, is symbolic of durability, strength, and the beneficial effects of medication. It is also likely that the Greek gods were based on real people possessed of outstanding abilities. Aesculapius, a physician who apparently cured many patients, was later deified as the son of Apollo. His staff and intertwined serpent are essential symbols of medicine today. Primitive Chinese medicine also attributed diseases to gods and demons, but it eventually developed into an extremely effective body of knowledge, which has recently enjoyed a resurgence of interest even in the western world.  The fact that Chinese civilization persisted for many thousands of years has made it accessible in modern times, unlike many others, which were lost to posterity. For example, all we know of Mesopotamian medicine is that Gilgamesh was its mythological hero. Hebrew medicine, partially borrowed from the Egyptian, uniquely emphasized hygiene, healthy foods, and sanitation.                                         

           There was a considerable exchange of medical knowledge between the Greek, Indian, and Persian civilizations, as rulers invited learned men from foreign lands to practice within their courts. For example, the first medical exams conducted in Persia, contained knowledge of senna and other herbs culled from Greek and Indian medical knowledge. Greco-Roman medicine borrowed a great deal from the Egyptians, and the concepts of disease developed by Pythagoras emphasizing different "humors," was developed as part of Ayurvedic lore many centuries before.  Hippocrates, born on the island of Cos about 460 AD, was a most astute Greek physician. The first doctor known to maintain records of his patients, he was able to effectively diagnose similar ailments in other patients. Hippocrates is, of course, best known for developing the physician's oath, now called the Hippocratic Oath. Hippocrates was philosophically humane toward his patients, and is, quite rightly, considered the father of medicine.

            As the history of medicine draws closer to modern times, it is evident just how much politics had its effect on what was considered appropriate treatment. Claudius Galen, a Greek born in 130 AD, went to Asia Minor at age 21 to study anatomy, to Alexandria to study the human skeleton, and repeatedly returned to Asia Minor to search for effective medications. He was anatomist, a physiologist, a pharmacologist, and a physician. Galen knew the arteries contained blood, and he had a good working knowledge of joints, muscles, and bones. However, since law prohibited dissection of humans he dissected only pigs, dogs, and apes. As learned as he was, he extrapolated his findings to man and some of these were grossly inaccurate. Galen's followers followed him blindly, and the teachings of Galen comprised the first "orthodoxy" of medicine. This actually resulted in the stagnation of medical knowledge and progress for more than a millennium.

            Paracelsus finally came in to challenge Galen. A rather mysterious figure, he was born in Switzerland in 1493 to a father who was a physician and a mother who was a hospital superintendent. Paracelsus studied physics and surgery and went to medical school in Vienna, but was intent on challenging the medical establishment as dictated by Galen. Paracelsus was exiled from Vienna for this, as well as studying witchcraft and alchemy, caused him to be summarily exiled.  He travelled widely from China to Constantinople, furthering his knowledge of pharmacoepia. Many of his biographers considered him a crank or a quack, but Paracelsus is considered the father of chemical pharmacology. He is in fact credited with introducing opium and mercury into the arsenal of medicine. Galen's principles were now under suspicion, and Leonardo Da Vinci opened the gates of knowledge wider by studying more than thirty corpses and making elaborate pencil sketches of them.  He helped to further the idea that what one experienced and saw with his own eyes was more important than the principles of the established medical orthodoxy.

            Science was beginning to have more of an effect on medicine. Galileo was an experimentalist, and his doubts regarding accepted facts led to his discovery of the acceleration of falling bodies. He also implemented the prior discoveries of the microscope and telescope, verifying Copernicus's theory that the sun was the center of the solar system.  Further discoveries inevitably followed: Leeuwenhoek, a Dutch grinder of lenses, also made a microscope in the 17th century and discovered "animalcules" in a droplet of water. This put him on the medical map as the father of microbiology. Medicine was now definitely assisted by science, and the dawn of the 20th century ushered in more technological discoveries, like the development of the X-ray machine (Kothari and Pai). But medicine was not really considered a science by most of its practitioners until much, much later, with the discovery of antibiotics. The question is: Did science and technology really improve the effectiveness of healing?

            They probably did, in terms of emergency medicine, and uncontrollable infection, and even practitioners of alternative medicine today would  not be likely to dispute this. However, no one knows exactly how effective the ancient forms of medicine actually were. Also, of necessity, much was left out of the timeline. We cannot really assume that any of the ancient methods were altogether useless. Even those that were present before recorded history must be considered.  Once any study of the history of medicine is undertaken, it is evident that modern medicine is merely part of the overall evolution of the healing arts in general. There is no real cutoff point at which information can be deemed valid and prior knowledge invalidated. As we shall see, the placebo effect was always a part of medicine whether or not this was part of the common wisdom.

            In the United States, the placebo effect used to be an integral part of conventional medicine, before much medical technology was available, and every practitioner knew this. Lewis Thomas describes both his father's medical training and his practice in Flushing, New York. Dr Thomas practiced medicine as the art form it still is, despite the veneer of science, which now surrounds it almost completely. In 1901, when Dr Thomas started his medical training, the profession had recently come out of a dark era of "therapeutic nihilism" in which purging, bleeding, raising of blisters and other atrocities were rampant.  The ideas of Sir William Osler, that most therapies cause more harm than good, had fortunately come into prominence and the emphasis was on diagnosis, or recognition of the symptoms and causes of disease. Doctors were expected to possess a capacity for affection as well as a good medical education. What was actually taught in medical school was the natural history of a disease, so that the best possible diagnosis could be made. This comprised the sum total of what was considered "science" in medicine.                                                                                                                     

         In the 1920's and 30's, doctors made a marginal living unless they "married wealthy," Every doctor made house calls, and was available throughout the night for the birth of babies and the inevitable less happy medical events. There was, frankly, very little in the way of effective pharmacoepia. A doctor's black bag contained a stethoscope, syringes, morphine, adrenaline, insulin, and digitalis. These substances had well-known, powerful effects. In addition, there were tonics and pills that were more or less useless, but toted around by the doctor anyway. Most patients felt emotionally reassured if at least some medication were prescribed. Many of them recovered, and Dr Thomas was respected as an extremely effective practitioner although he asserted that the diseases had simply run their course. After all, even the worst illnesses did not kill everyone. The practice of medicine relied heavily upon the close relationship between the doctor and his patients. In conventional western medicine it is even now not really accepted how much its effectiveness, and the rate of patient recovery, is dependent upon this.  At the time Dr Thomas, Sr., was practicing there was little otherwise available in the medical arsenal, and it certainly was not believed at that point that the placebo effect might be a real, discernible phenomenon worth cultivating and studying. Use of the placebo effect was sort of an embarrassment, and most physicians wished they had more at their disposal with which to help the patients. Dr Thomas Sr. was not a maverick in his profession, but a sensible sort who did not get involved in what he considered fads. Wishing that he could do more good for his patients, Dr Thomas was disappointed in his profession until he got involved in surgery, at which he was especially talented. It is not particularly surprising that, unlike many surgeons, he refused to operate unless it was absolutely necessary (Thomas, Notes).  Dr Thomas employed the placebo effect every day of his professional life, even without conscious awareness, and his patients were all the better for it.

            Much has changed since Dr Thomas studied and practiced medicine. House calls of course are a thing of the past.  In the 1920's, the effort was made to advance the profession scientifically, and research laboratories began to be associated with major hospitals and medical colleges. In terms of discoveries, the results were astounding. Antibiotics began to be discovered, and immunology became an applied science. Yet much has also been lost. Today, doctors are expected to assess the condition of their patients based an empirical process. "Empirical" is another word which is much bandied about in medical/scientific circles but not widely understood by the lay public. Most dictionaries, when consulted, yield a definition similar to this one:

empirical

ADJECTIVE: 1a. Relying on or derived from observation or experiment: empirical results that supported the hypothesis. b. Verifiable or provable by means of observation or experiment: empirical laws.        2. Guided by practical experience and not theory, especially in medicine.

            Most people believe that empirical or "evidence-based" knowledge is information that has been absolutely proven via the scientific method. This is a false assumption. First of all, in clinical medicine, i.e. in a clinic, hospital, or doctor's office, perfectly valid observations may be made without the use of the scientific method at all. Lewis Thomas also referred to a physician who could diagnose patients to a high degree of accuracy through his own perceptions, and by touching the patient. Andrew Weil in "Health and Healing," made mention of another such person skilled in this very same art form. Did physicians lose this ability? Perhaps few medical professionals possess this kind of gift, and the rest need to rely on the accuracy of scientific experiments and technology. My other point, which I will illustrate later on, is that science and medicine are replete with experimental inaccuracies.  Here is a radical concept: Perhaps we have been going down a blind alley by fixing on the belief that scientific medicine is a necessity for healing.

            The healing arts have been practiced long before the medical timeline that I delineated, long before recorded history, from the time that human beings first walked upright on this planet. And a good deal of it might well have been effective. Many cave paintings, hundreds of thousands of years old, show a person who is recognizably a shaman, or ritual healer. Shamans still exist today, in Siberia and in tribal cultures, particularly among hunter-gatherers. The Native American "medicine man" was a shaman, as was the Voodoo Bokor, and he was a respected, feared personage.  In these societies, as in ancient China and Greece, illnesses were believed to be caused by evil spirits or natural forces, not microbes, genetic defects, or even accidents. Someone might fall on his knife, but what made this happen? The shaman would travel to a desolate spot, meditate on the afflicted person, and possibly take hallucinogens for inspiration. Trances, whether induced by drugs or exposure to the elements, are a hallmark of shamanic medicine and many cures took place in this milieu as well. Today, civilized people may not believe in vengeful spirits but it is necessary to accept that the shaman's actions had a powerful psychological effect on the person he was healing.  This is the essence of the placebo effect: The healer acts as a catalyst upon the patient. We don't know the exact mechanism of how this occurs, but somehow the person's own innate healing abilities begin to work. The person's confidence, or faith in the healer's abilities have always been a crucial part of the equation. The power of suggestion has been observed to effect complete cures in any number of illnesses. An observable phenomenon that has this kind of effect, whether understood or not, should certainly be utilized in clinical medicine. That the Sagans and Parks of the world might disagree with this assessment seems, in a word, ridiculous.

            According to Andrew Weil, MD, all healing takes place within the patient, and any healer, whether modern physician or shaman, is merely a catalyst. The placebo effect, he believes, is essentially the interaction between the patient, the healer, and the patient's system of beliefs. What is operative is the power of suggestion. The placebo response is essentially a psychosomatic effect, a much-misunderstood term which simply signifies "mind-body." There is no way, in truth, to separate the mind from the body it inhabits and the two work in tandem with each other. Although people may seem to differ in their suggestibility, Weil believes that every person, under the proper fortuitous circumstances, is capable of generating in himself a healing response. Medicine has always been philosophically aligned with magic and religion, a fact that is lately denied but was made evident in the timeline. Most religions have as their essence the idea of god as a perfect being and the universe as being possessed of perfect orderliness. The word "medicine" actually has Indo-European roots, suggesting appropriate action to establish order. Health is not really the absence of disease, but the ability to maintain order, or perfect balance. This concept actually has a scientific basis, in terms of dynamic equilibrium. Equilibrium is often thought to be a form of stasis, but in terms of chemistry it indicates that all reactions are occurring at an equal rate, and it merely appears that nothing is happening. If health is such a complicated balance of forces, how can it be achieved and maintained? Foremost is the belief of the individual that this is possible. The healer facilities this both by reinforcing the patient's belief system and reassuring him that he has the capacity to assist him in returning to a healthy state. If the person is in the proper state of mind, it seems, illness will have little or no effect upon him. This is the case regardless of the presence of disease-causing agents. Touching the patient is an intrinsic part of the process. Touching is a primary factor in most therapeutic systems. Medical students are frequently told to touch the patient, but they are not told that healing might fail to occur if they don't. Most people who are ill would like to be touched. In point of fact, both human and animal nervous systems are so sensitive to touch, newborn infants deprived of physical touch fail to develop, sicken, and die (Montagu). Comfort and a good bedside manner seem at this point to be more critical to patient care than a fast-acting drug or a good medical education.

            Dr Weil is one of those who believe that the key to the placebo effect lies in the nervous system. Although some scientists believe that not enough proof yet exists, there are many situations in which the placebo response has clearly been taking place. For example, a recent study showed that placebo as pain-reliever may be due to the body's production of endorphins, nature's opioids. Placebos that improve motor function seem to have caused the release of dopamine. In the experiment, the pain-relieving effect was in fact halted by administration of an opioid-blocker (Benedetti).

            Any mind/body effect can be thought of as a placebo response. All therapeutic measures, however effective, act as placebos as well. It is therefore possible to facilitate the body's own innate ability to heal, regardless of what therapeutic measures are available and whether or not they are effective. This is a revelation, but does not negate the usefulness of ordinary medical therapies, and does not make the effort to advance medical science useless. The placebo effect can and does act as an enhancement. All drugs which have an active effect also have a placebo effect. Thus, their effect is the sum total of active principle plus placebo effect.  Heart patients, after bypass surgery, are told to calm down and even to change their personalities if possible. The effect of the mind on the body is not understood, but it certainly has been observed and is even grudgingly accepted.

            Why the acceptance is reluctant is another matter worthy of consideration. Self-healing is a concept that is extremely threatening to medical practitioners who entered the field in order to gratify their egos. A world where the patient could heal himself would undermine the authority of such practitioners, as well it should. Another truism about the placebo response is that any form of medical intervention often seems to be better than none. The simple act of offering treatment, or attention, is also known to elicit a healing response (Weil).

            The placebo effect is clearly valuable, and if it constitutes the basis of the healing response it certainly is worth learning to control. If the placebo effect does take place in the nervous system, perhaps advances in neurology can even help us learn how to wake up the power to heal ourselves. Viktor Frankl, a psychiatrist and Holocaust survivor, noticed that people fell prey to illnesses like typhoid and died only when they lost hope that they might someday be rescued. His observations led to the development of a new form of psychology he called "Logotherapy" (Frankl).  Some people, like Norman Cousins, discovered that laughter could heal.  During several episodes of serious illness, he used his instincts regarding what might help when medical science offered him no solution. He recovered completely each time (Cousins). We don't know exactly what neurotransmitters were mobilized in these cases, but this may someday be known. Science, of course, did not create in Cousins the ability to heal himself. Both situations laid the groundwork for a new science called psychoneuroimmunology, which is the study of how the mind can affect the immune system.

            Dr Weil and others have pondered the existence of the brain chemicals called endorphins. Their purpose has always been highly obscure, and, historically they have caused a great many problems. Drug addiction, after all, is a result of narcotics being able to fit into the brain's endorphin receptors like thieves possessing the master key to a lock. More and more, it seems a necessity that we learn to harness the brain's capabilities (Weil).

            The place of placebos in clinical trials, meaning medical experiments involving subjects, is not as easy to determine as whether or not placebos should be used as part of a medical treatment. Placebos were first used in clinical trials in 1907, to determine the influence of alcohol and other drugs on fatigue. In the 1920's and 30's there were some placebo-controlled studies, but these were not "blind," meaning that someone, either the subjects or the researchers, knew who were given the placebos. This is now considered a flawed study design, and by the 1950's a pharmacologist named Harry Gold had established the standard for double blind, placebo-controlled studies in clinical trials. By the 1970's, the FDA started recommending that safety and efficacy trials of new drugs used a double-blind design with placebo controls whenever possible and ethical. This design standard was widely adopted, although never mandatory (Hart). It appears that no study design is foolproof, however. Many drugs which have been accepted by the FDA, like certain antidepressants, were tested again and found to be no more effective than placebos alone. In addition to this, many drugs that have been approved by the FDA can nonetheless have unexpectedly deleterious effects. This is supposed to be predictable in a statistical sense, but in reality, the results of almost every study are so grievously flawed one should always suspect an enormous amount of error. This is partly due to the ubiquity of the placebo effect, which exists as stated before regardless of what drug is given. One might think that if the placebo always exists, one could just cancel it out in all situations, as one can in mathematics when a numeral is added to both sides of an equation. The fallacies here are manifold; in fact, each person's state of health is different at any point in time and so even for one person the conditions are not repeatable. It is also due to our own biochemical individuality. Each person is unique, and the state of health or balance of his various organ systems is not equivalent to any other subject in the study, however randomly they were selected. In fact, we are internally far more variable than our external bodies would indicate. Roger J Williams, a biochemist best known for the discovery of Vitamin B-5, made this subject his life's work. For instance, astonishing as this might seem, our stomachs are so variable in size that if our noses varied similarly, one might be the size of a pea and the other, a watermelon. Our blood supply to various organs is at least as variable. It goes without saying that our degrees of suggestibility, or ability to mobilize the placebo effect, vary at least as much. Our responses to drugs are so different, many subjects experience effects in direct opposition to others. An experience of this kind was the motivating factor for Dr Williams. At one point in his life he was hospitalized and given morphine as a sedative and pain reliever. What happened to him was what usually happens when a person is given amphetamines; his metabolism speeded up drastically, Once informed of this effect, the hospital staff gave him more morphine, and he began to "speed" even more (Williams).

            I myself have experienced these kinds of effects, and I know of many situations where others have as well. For instance, I cannot take "Sudafed," or pseudoephedrine for colds during the day, as even half the usual dose puts me into a semiconscious state. This product is marketed as a "non-drowsy" decongestant, but I have been told by pharmacists they believe it makes at least 10% of the population very sleepy indeed. My uncle and my brother both suffered adverse effects to antibiotics they were given while in the hospital as a preventative measure. In both their cases, extreme hallucinations were the result. Adverse drug effects were not suspected in either case. My uncle was deemed a crazy old man, until my mother came in asserting that he had no mental problems. My brother, fearful that he would suffer permanent neurological impairment, pulled out his own IV when the hospital refused to curtail the medication. These sound like extreme cases, but medical lore is rife with them. In "The Disembodied Lady," Oliver Sacks details a similar one. Given antibiotics before a routine gallbladder operation, a young woman awoke to find she had lost all sense of proprioception, the ability to perceive where one's body is in space. Closer examination revealed nerve inflammation, and she was never to recover this ability.  She had, curiously enough, experienced a dream that night that she didn't know where her body was (Sacks 43-54).  Science at this point cannot explain this sort of sleeping awareness any more than it can explain the other mental powers we may possess.

            It is not surprising that there is far more criticism of the use of the placebo effect in clinical trials than whether or not their results have any degree of accuracy under any circumstances. Most of the objections are related to study design, and the effort to control the placebo, which is ironically enough supposed to be the "control." The necessity that subjects give informed consent, a necessity by international law (World Medical Association), is also suspected of having a placebo effect, which further erodes the controllability of the experiment. Some scientists feel that giving placebos to critically ill patients is unethical when other, more active compounds are known to exist. This is a comical notion, given the both the inaccuracies in the testing of drugs, and our widely variable response to them.  Still others simply recommend that if all studies included a very large number of subjects, all of these factors would diminish in importance and the accuracy of the studies would greatly improve (Hart).  It appears that experimental trials involving human subjects are, at this point in time, far from controllable despite all the efforts made to ensure their accuracy. Every medication, once it is approved by the FDA, has a written disclaimer in very small print as to what the "side effects" might be. In truth, all are effects. The process and results of drug testing seem so ludicrous that one is tempted to look askance at all drug evaluations, and act with extreme caution when taking them. So much for scientific accuracy, it is not necessarily what it is purported to be. My own conclusion is that the effects of pharmaceuticals are questionable, and should be avoided, whenever possible.

            There is a need to discuss how the idea of self-healing fell out of favor, and whether or not it should be resurrected. Galen may well have been the first purveyor of "medical orthodoxy," but he was not the only one. Medicine has always been subject to the whims of those who hold political power. The "therapeutic nihilism" that Lewis Thomas referred to was also known by its practitioners as "heroic medicine." Heroic is a strange term to use for the barbaric medical practices used from about 1740 to 1850. But the word also signifies melodrama, and grand sweeping gestures, and they certainly were that, if nothing more. They were in fact both sadistic and extremely infective. 

            In the 1700's, medicine was exclusively male and elitist. William Cullen, head of the prestigious University of Edinburgh was its chief theoretician and he was convinced that all medical problems were caused by "bad blood." Therefore bleeding was the treatment of choice for any and all illnesses. Cullen's chief disciple in America was Benjamin Rush, a signer of the Declaration of Independence and a heroic physician extraordinaire. Cullen stated frequently that he would rather die than give up his lancet, which was the instrument used to cut and therefore bleed the patient. Heroic medicine undoubtedly was the cause of George Washington's death. His initial symptom when seeking medical help was a severe sore throat; the treatment was repeated bloodletting. In short order, he was too dehydrated to yield more than a few drops of blood and therefore Spanish fly, a blistering agent, was applied to his throat. The next step was the administration of calomel, an extremely toxic "heroic measure" which was supposed to eliminate toxins from the body. These remedies had the inevitable, fatal effect upon the patient.

            There was some opposition to these extreme forms of treatment, but it was largely ignored. Other healing traditions continued to exist, such as the herbalism of European and American country women. They were not permitted entry to any medical school, and no trained physician would associate with them. In 1772 American heroic physicians obtained for themselves favorable legislation, which issued medical licenses only to members of their exclusive societies. The excesses of heroic medicine and its political domination eventually led to the "Popular Health Movement," typified ideologically by Jacksonian Democrats who believed any monopoly was contrary to freedom. By the 1840's the Popular Health Movement seemed about to prevail; also coexistent was a strong women's movement, which stressed preventative care and classes to learn about their bodies. For a time, the Popular Health Movement did succeed; restrictive licensing laws were repealed. This incensed the Heroic Physicians and they resolved to put everyone interested in less invasive measures out of business. 

            In 1843, Homeopathy was developed in Germany and strangely enough served as ammunition for the Heroic Doctors. Samuel Christian Hahneman had received his medical license in 1779, lost faith in heroic measures, and became interested in stimulating health in sick people. He was greatly disturbed by the thoughtless prescription of drugs such as calomel, and decided to do his own testing of drugs in the heroic pharmacopeia. What he observed went against all previous medical principles, at least those known in the western world. Hahneman discovered, among other things, that extremely diluted doses of a medication could have a stronger, more salubrious effect on illness than concentrated doses. He also came to believe that drugs producing an effect symptomatically akin to the illness had the ability to cure it. Hahnemen's methods were based on his observations, not on chemistry, and they immediately came under fire from the recently dethroned heroic establishment, which he dubbed "Allopathy," meaning other than the disease. His own method was called "Homeopathy," or like the disease. The thing was, Hahnemen's methods often worked. If Homeopathy possesses any underlying scientific principles, they are as yet unknown, more than 150 years later. It is likely that Homeopathy mobilized the placebo response in a great many people, and as we have shown this can be extremely effective. It certainly has never been known to be harmful. Hahnemen was a proponent of the gentlest and most important line of the Hippocatic Oath, which reads, "First, do no harm." Hahneman was not a charlatan, intent on bilking the public out of their money. His mission was, quite simply, healing the body. This was in direct opposition to the principles of the Heroics or Allopaths, who quickly organized, formed the American Medical Association, and published a great deal of propaganda against Homeopathy. This also had the effect of squashing the Popular Health Movement, and medicine has never really been the same since. The Allopaths are in power, and their platform has evolved to being more scientific in nature, but they are still elitist and extremely exclusionary. These days there does seem to be a resurgence of some of self-determinism inherent in the Popular Health Movement. If the public becomes disgusted enough with the effectiveness of medical treatments, perhaps these attitudes will prevail (Weil 12-25).

            There are many more Hahnemans, whose methods of treatment go against the body of scientific knowledge, or against the medical establishment. They almost always come under attack, ostensibly for the protection of the public. One such person was William Horatio Bates, an ophthalmologist born in Newark, NJ who received his medical degree in 1885. He practiced privately and in hospitals, but he could not help noticing that the vision of nearly all of his patients was extremely variable. This suggested to him that it could be improved, and he set out to discover how this could be accomplished. He gave up his practice in order to devote his life to the study of how eyesight could be improved, and his conclusion was that this could happen only through the relief of mental strain. Bates's method and his book, The Cure of Imperfect Eyesight, are full of suggestions on how relief of strain can be achieved. Some of Bates' principles go against known principles of physiology, such as his assertion that accommodation (fine focusing) exists in the lensless eye. Bates quite possibly is wrong that this occurs, but his method often works. We don't know how this happens, but he certainly was not a charlatan. It's very likely that the Bates Method works via the placebo effect, and it certainly does no harm. Vision professionals often insist that trying the Bates Method prevents patients from seeking appropriate effective medical care. This is the usual argument, but most people who are interested in the Bates Method have exhausted all other possibilities. In other words, they have been told by their doctors that their cases are hopeless (Bates, Kiesling). Bates has as two of his success stories the writer, Aldous Huxley, and myself.

            I suffered an eye accident in 1986, while working in a jewelry factory. I was struck directly in the eye by a piece of metal, which required immediate corneal surgery. My eye doctors told me that the shock of the impact caused my ciliary, or fine focusing muscles to go into spasm and I lost the ability to use my eyes in a binocular fashion. They offered me "Vision Training," which is a practice taught by a few optometrists to patients, mainly with binocular vision problems. I found the exercises extremely difficult, and was about to give up when I heard about the Bates Method. I was fortunate inasmuch as I had never read any of the literature opposing the use of the method. I didn't know anything about it at the time, or anything about the physiology of the visual system. I found the Bates method to be very helpful, and was soon able to go on to the much more challenging Optometric Vision Training exercises. I also employed both the Bates Method and Vision Training some years later, when I had developed presbyopia, or "middle-aged eyes." I have since then read the arguments against Bates, but my own experiences supersede any comments penned by other people. Why did the method work, in lieu of a scientific basis? It is probably the placebo effect at work, once again. The Bates Method is attacked by both optometrists and ophthalmologists alike. Even Vision-Training Optometrists target him, although Vision Training as a therapy was first suggested by Bates' observations. That method was finally developed by A. M. Skeffington about fifty years ago, and its effectiveness has a very sound neurological basis (Press). Alas, there is much we don't know about the workings of the human mind and its associated structures, the brain and nervous system. The relationship between the Vision Trainer and patient are of primary importance, as is the attitude of the patient. This is a difficult thing to control, as many of the patients are young children. Much of the improvements observed during Vision Training are also difficult to duplicate in experimental situations. Practitioners of Vision Training, comprising only 1% of the Optometric community, know that it is an art form, although it is statistically an extremely effective method. They decry the lack of respect they receive from other Optometrists and Ophthalmologists. I wish they would be more pleasant to Bates Method teachers and practitioners. There is little doubt in my mind that the placebo effect is a primary reason for the effectiveness of both methods.                                                                                            

            Given the pitfalls of using the placebo effect, and the difficulty in controlling it, one wonders if it ever should be used at all. The answer is an unequivocal yes. As a young child, my family physician was Dr. Lyon Stein. He was a person who seems, in retrospect, very much like the father of Lewis Thomas. Kindly, genial, he never failed to come to our home when we were ill. He joked with us, and praised us, even for small things such as how much we had grown or how good our posture was. Dr. Stein was actually a very learned man, who was a colleague of Linus Pauling, the proponent of Vitamin C for health. In those days one had to purchase the vitamin in a syrup form, by prescription from a pharmacy. Dr. Stein's methods may or may not have kept us healthy. His attitude certainly did, and the feelings it engendered in all of us. How is it possible that this factor could fall into disuse and disfavor?

            I have suggested the possible reasons, but they scarcely seem to matter unless one is intent upon living in the past and suffering for the mistakes that have been made. It is apparent that the mind/body of every person is unique, and this fact cannot be treated lightly. In order to maximize the powers of the mind/body system, we need to surround ourselves with practitioners such as Drs. Stein and Thomas. The human race is called "Homo Sapiens," which indicates that we have the strong desire to be wise, to amass knowledge, to learn, in order to understand the world around us. Science has given us many new tools with which to learn, but we are at this point far from competent at using them. We should not forget that. One is forced to return to contemplating the wonders and unexplainable mysteries of nature, and as we travel into the future intent on seeking knowledge, we should never, ever fail to grant them the respect that is their due.

© Francine Eisner  2004

Works Cited

Bates, William Horatio, The Cure of Imperfect Eyesight, Central Fixation Publishing Co., NY,     1919

Benedetti, F., "How the Doctor's Words Affect the Patient's Brain," Evaluation of Health             Professionals,December 25, 2002, Medscape WebMD, University of Turin Medical             School,http://intap.medscape.com

Cousins, Norman, Anatomy of an Illness,

Feynman, Richard P., The meaning of it All: Thoughts of a Citizen-Scientist, Perseus Books, Reading, Massachussetts, 1998

Frankl, Viktor E., Man's Search For Meaning, Simon & Schuster, New York, 1959

Hart, Carol, The Mysterious Placebo Effect: Understanding It Can Avoid Flawed Study Designs,"Modern Drug Discovery, http://pubs.acs.org/hotartcl/mdd/aug/mysterious.html

Kiesling, David, "Introduction To W.H.Bates," Seeing.org, http://www.seeing.org/intro/history/history.html

Kothari, S.N, and Pai, Sanjay A., An Introduction To The History of Medicine Online,http://www.histmedindia.org

Montagu, Ashley, Touching: The Human Significance of the Skin, Columbia University Press,      New York  and London, 1971

Park, Robert L., Voodoo Science: The Road From Foolishness To Fraud, Oxford University         Press, Oxford, New York, 2000

Press, Leonard, "Vision Therapy FAQS," VisionTherapy.Org, http://www,visiontherapy.org/vision-therapy/faqs/vision-therapy-FAQS.html

Sacks, Oliver, The Man Who Mistook His Wife For A Hat, Harper Perennial, New York, 1970

Sagan, Carl, The Demon-Haunted World, Random House, New York, 1995

Thomas, Lewis, The Medusa and the Snail: More Notes of a Biology Watcher, The Viking Press, New York, 1979

Thomas, Lewis, The Youngest Science: Notes of a Medicine-Watcher, The Viking Press, New York, 1983

Weil, MD, Andrew, Health And Healing, Houghton Mifflin Company, Boston, New York, 1995

Williams, Roger J, You Are Extraordinary, Pyramid Books, New York, 1971

World Medical Association, "World Medical Declaration of Helsinki: Ethical Principles for Medical Research Involving Human Subjects," first adopted in 1964,  http://www.wma.net/e/policy/b3.htm

Disclaimer: This article is not intended to provide medical advice, diagnosis or treatment. Views expressed here do not necessarily reflect those of GreenMedInfo or its staff.

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