Monday, April 9, 2012

In defense of placebos


I'm pretty much a non-interventionist when it comes to health and healing.  Whether that's a luxury I enjoy because I'm usually in good health -- or whether I'm usually in good health because I stay away from the meddling of healers -- I can't say.  I hit up my doctor for doxycycline when I get the tell-tales for Lyme disease, I had surgery when a salivary gland went bad, but otherwise I mostly rely on my body to heal itself.  I listen to my body when it has something to say to me, and eat plenty of multi-grain bread with butter and Monica's fantastic cooking.

As an anthropologist and sometimes pagan, I'm sympathetic to the theatrics of "alternative healing" even if I'm fairly skeptical of the mechanics.  But when Brian Kaller, of Restoring Mayberry, of one of my favorite blogs, laid out a more consistently skeptical takedown of alternative medicine it struck a chord.  An excerpt:
Most people I know, in one way or another, yearn for a simpler and more natural way of life, a way to get around big government and big corporations and deal with authentic people, to buy products whose ingredients they can pronounce. And so markets and movements have arisen to meet that demand, and give people the illusion of doing that . . .
Some of the ways people try to live a more natural life, however, just do harm. Refusing vaccinations does not restore the collapsing plankton levels in the ocean, it just makes your children more vulnerable to disease. Buying “herbal” medicines sends money to corporations – just corporations that can work outside of mainstream medicine’s public rules, and so get to sell things that don’t work. 
I'm neither a doctor nor a politician, but I can think of a number of ways people can improve their and their neighbours' health. They could persuade many people to garden, getting excercise and fresh vegetables. They could persuade lawmakers to force herbal companies to abide by the same standards as pharmaceutical companies . . . Americans could also persuade lawmakers to change health-care laws, imitating what seems to work best in other parts of the world.
If more people feel sick, stressed and helpless in years to come, however, the danger is that, instead of doing any of these real things, they will be a prime target for hucksters selling placebos – things that only make them think they are fighting the good fight. 

With slightly tipsy ambivalence, I tried to think through the redeeming features of quackery:

(more below the fold)

That's a big topic you've bitten off today, and I can think of a few responses I'd like to make. I'll limit myself to a traditional anthropological observation though. People resort to magic when they've reached the limit of what (they believe) they can do in the "real world". Azande potters knew all about working the clay and managing the temperature and so on, but still, sometimes the pot cracks in the heating. And to deal with that there is only magic or prayer. In your descriptions of healing and quackery, I see that dynamic. There are things we (believe we) can do or (we believe) modern medicine can do about our health and maladies. But maybe scientific medicine can't help us or we've lost our belief in it. Since "doing nothing (!)" isn't an option, we will inevitably do something that we're convinced will have an effect. And oddly enough, the human body seems to respond pretty positively to such a stratagem (e.g. the "placebo effect"), so the cycle gets reinforced.

In that part of the spectrum of human malady that responds to the placebo affect (and it is wider than most people realize), that's fine - and there I think is where much alternative medicine succeeds. Of course, scientific medicine has some pretty good mechanical cures that people are foolish to reject, and there are also serious mechanical problems that can crop up in the body that no amount or belief in quackery will cure.

To circle back to my Azande potters, I think my point (and I'm mostly through my third black and tan here, so be charitable) is that the trick is to keep track of the clay and the temperature before you resort to magic -- BUT, oddly enough the human body responds to magic in a way that the clay really doesn't. And for that reason I see the magic of alternative medicine as playing a more constructive role than most garden variety magic.

Thanks for the thoughtful response. I agree that placebos can have a powerful effect, and I suspect this is why alternative medicines, prayer, magic rituals and faith healers seem to work, at least for a while. I think it’s important to make two ethical distinctions, though. Firstly: prayer and sugar pills cost you nothing, while faith healers and homeopaths are profitable enterprises. 

Secondly: It’s one thing to pray for the sick because it’s the kind thing to do -- I’m told people do get better faster when they know people are praying for them, and it certainly won’t make the situation worse. That’s not the same, though, as faith healers or alternative therapies, however, in which people are told the intervention is literally eliminating the pathogen. The latter basically assures someone they don’t need to see a doctor anymore – which could cost them their lives. 

I don’t have any more sympathy than you for charlatans who dissuade people from effective healing.  I just wanted to make an observation and maybe take the opportunity to sort out my own thinking on the topic. 

There is a “mechanical” effect that physically operates on a physical problem (e.g. a chemical that causes veins to dilate, a bacteria the produces toxins in the tissues).  There’s also the “psychological” effect that can affect the body physically (e.g. the placebo affect, psychosomatic ailments, toxic stress, the power of positive thinking, etc.).  For thousands of years people have used both – coupling actual mechanical effects with all the “theater” of healing and quackery to strengthen, focus and direct the psychological effects.  In my opinion a school of healing worthy of the name makes use of both of these.  In truth, for its day to day success modern medicine relies both on mechanics and on the psychological effects (e.g. placebo effect) that comes from people’s faith in science and medicine.  (This is probably one reason why doctors so long insisted on all the trappings of authority – and the more recent disdain for human psychology is one reason why despite their impressive arsenal of treatments, modern doctors so often fail at actual healing.)  I think herbalism, massage, chiropractics, etc. also manage both aspects, the mechanical and the psychological.  There are others, like homeopathy, crystals, faith healing, that (in my opinion) can only avail of the second – and that makes them much, much weaker in general and completely inappropriate for healing things beyond the body’s psychosomatic abilities.

I guess what I’m saying is that a crystal healer who cures someone’s tension headaches is doing good work, (indeed better than the M.D. with his pain pills) while a crystal healer who says they can replace chemotherapy is a dangerous quack who needs to be shut down.  On the other hand, I think that a doctor who considers it enough to prescribe Lipitor for the suicidal American diet, isn’t much of a healer either.


A fair point, although on the spectrum between the examples you give, where would you draw the line?   I wonder, based on what you've said, if one could measure the effectiveness of treatments when people had more faith in the treatment. 


I suppose I would draw the line at the traditional, "do no harm". That still leaves plenty of space for argument and discussion, however. Harm to the bank account is certainly a form of harm. And maybe leading people into superstition or misunderstanding of the world is a significant harm as well.

As for the science, there's a good rundown on some of the efforts to tease out what exactly is the placebo effect at skepdic. Sometimes the placebo effect just shows that people would've gotten better on their own (more or less regardless of whether the treatment was drugs or sugar pills) and sometimes the placebo seems to have actual physiological effects. In any case, I still think the whole mess of effects is integral to any effort to heal people, and healers have been sensitive to that fact for as far back as we can see. 


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