Bad Science (8 page)

Unfortunately this idea turned out to be nonsense, but only after a fashion. In 1959 a placebo-controlled trial of the operation was performed: in some operations they did the whole thing properly, but in the “placebo” operations they went through the motions but didn’t tie off any arteries. It was found that the placebo operation was just as good as the real one—people seemed to get a bit better in both cases, and there was little difference between the groups—but the strangest thing about the whole affair was that nobody made a fuss at the time. The real operation wasn’t any better than a sham operation, sure, but how could we explain the fact that people had been sensing an improvement from the operation for a very long time? Nobody thought of the power of placebo. The operation was simply binned.

That’s not the only time a placebo benefit has been found at the more dramatic end of the medical spectrum. A Swedish study in the late 1990s showed that patients who had pacemakers installed but not switched on did better than they had been doing before (although they didn’t do as well as people with working pacemakers inside them, to be clear). Even more recently, one study of a very hi-tech “angioplasty” treatment, involving a large and sciencey-looking laser catheter, showed that sham treatment was almost as effective as the full procedure.

“Electrical machines have great appeal to patients,” wrote Dr. Alan Johnson in
The Lancet
in 1994 about this trial, “and recently anything to do with the word LASER attached to it has caught the imagination.” He’s not wrong. I went to visit an alternative therapist once, and she did gem therapy on me, with a big shiny science machine that shone different-colored beams of light onto my chest. It’s hard not to see the appeal of things like gem therapy in the context of the laser catheter experiment. In fact, the way the evidence is stacking up, it’s hard not to see all the claims of alternative therapists, for all their wild, wonderful, authoritative, and empathic interventions, in the context of this chapter.

In fact, even the lifestyle gurus get a look in, in the form of an elegant study that examined the effect of simply being told that you are doing something healthy. Eighty-four female room attendants working in various hotels were divided into two groups. One group was told that cleaning hotel rooms is “good exercise” and “satisfies the Surgeon General’s recommendations for an active lifestyle,” along with elaborate explanations of how and why; the “control” group did not receive this cheering information and just carried on cleaning hotel rooms. Four weeks later, the “informed” group perceived themselves to be getting significantly more exercise than before and showed a significant decrease in weight, body fat, waist-to-hip ratio, and body mass index, but amazingly, both groups were still reporting the same amount of activity.
⁹

As you will now be realizing, in the study of expectation and belief, we can move away from pills and devices entirely. It turns out, for example, that both what the doctor says and what the doctor believes have an effect on healing. If that sounds obvious, I should say they have an effect that has been measured, elegantly, in carefully designed trials.

Gryll and Katahn (1978) gave patients a sugar pill before a dental injection, but the doctors who were handing out the pill gave it in one of two different ways: either with an outrageous oversell (“This is a recently developed pill that’s been shown to be very effective…effective almost immediately…”) or downplayed, with an undersell (“This is a recently developed pill…personally I’ve not found it to be very effective…”). The pills that were handed out with the positive message were associated with less fear, less anxiety, and less pain.

Even if he says nothing, what the doctor knows can affect treatment outcomes; the information leaks out, in mannerisms, affect, eyebrows, and nervous smiles, as Gracely (1985) demonstrated with a truly ingenious experiment, although understanding it requires a tiny bit of concentration.

He took patients having their wisdom teeth removed, and split them randomly into three treatment groups: they would have salt water (a placebo that does “nothing,” at least not physiologically) or fentanyl (an excellent opiate painkiller, with a black-market retail value to prove it), or naloxone (an opiate receptor blocker that would actually increase the pain).

In all cases the doctors were blinded to which of the three treatments they were giving to each patient, but Gracely was
really
studying the effect of his doctors’ beliefs, so the groups were further divided in half again. In the first group, the doctors giving the treatment were told, truthfully, that they could be administering placebo, or naloxone, or the pain-relieving fentanyl; this group of doctors knew there was a chance that they were giving something that would reduce pain.

In the second group, the doctors were lied to; they were told they were giving either placebo or naloxone, two things that could only do nothing or actively make the pain worse. But in fact, without the doctors’ knowledge, some of their patients were actually getting the pain-relieving fentanyl. As you would expect by now, just through manipulation of what the
doctors believed
about the injections they were giving, even though they were forbidden from vocalizing their beliefs to the patients, there was a difference in outcome between the two groups. The first group experienced significantly less pain. This difference had nothing to do with what actual medicine was being given or even with what information the patients knew; it was entirely down to what the doctors knew. Perhaps they winced when they gave the injection. I think you might have.

Placebo Explanations

Even if they do nothing, doctors, by their manner alone, can reassure. And even reassurance can in some senses be broken down into informative constituent parts. In 1987, Thomas showed that simply giving a diagnosis—even a fake “placebo” diagnosis—improved patient outcomes. Two hundred patients with abnormal symptoms, but no signs of any concrete medical diagnoses, were divided randomly into two groups. The patients in one group were told, “I cannot be certain of what the matter is with you,” and two weeks later only 39 percent were better; the other group was given a firm diagnosis, with no messing about, and confidently told they would be better within a few days. Sixty-four percent of that group got better in two weeks.

This raises the specter of something way beyond the placebo effect, and cuts even further into the work of alternative therapists, because we should remember that alternative therapists don’t just give placebo treatments; they also give what we might call placebo explanations or placebo diagnoses: ungrounded, unevidenced, often fantastical assertions about the nature of the patient’s disease, involving magical properties, or energy, or supposed vitamin deficiencies, or “imbalances,” which the therapist claims uniquely to understand.

And here it seems that this placebo explanation—even if grounded in sheer fantasy—can be beneficial to a patient, although interestingly, perhaps not without collateral damage, and it must be done delicately; assertively and authoritatively giving someone access to the sick role can also reinforce destructive illness beliefs and behaviors, unnecessarily medicalize symptoms like aching muscles (which for many people are everyday occurrences), and militate against people’s getting on with life and getting better. It’s a very tricky area.

I could go on. In fact, there has been a huge amount of research into the value of a good therapeutic relationship, and the general finding is that doctors who adopt a warm, friendly, and reassuring manner are more effective than those who keep consultations formal and do not offer reassurance. In the real world, there are structural cultural changes that make it harder and harder for a medical doctor to maximize the therapeutic benefit of a consultation. First, there is the pressure on time; a doctor can’t do much in a six-minute appointment.

But more than these practical restrictions, there have also been structural changes in the ethical presumptions made by the medical profession, which make reassurance an increasingly outré business. A modern medic would struggle to find a form of words that would permit her to hand out a placebo, for example, and this is because of the difficulty in resolving two very different ethical principles: one is our obligation to heal our patients as effectively as we can; the other is our obligation not to tell them lies. In many cases the prohibition on reassurance and smoothing over worrying facts has been formalized, as the doctor and philosopher Raymond Tallis recently wrote, beyond what might be considered proportionate: “The drive to keep patients fully informed has led to exponential increases in the formal requirements for consent that only serve to confuse and frighten patients while delaying their access to needed medical attention.”

I don’t want to suggest for one moment that historically this was the wrong call. Surveys show that patients want their doctors to tell them the truth about diagnoses and treatments.

What is odd, perhaps, is how the primacy of patient autonomy and informed consent over efficacy, which is what we’re talking about here, was presumed but not actively discussed within the medical profession. Although the authoritative and paternalistic reassurance of the Victorian doctor who “blinds with science” is a thing of the past in medicine, the success of the alternative therapy movement—practitioners mislead, mystify, and blind their patients with sciencey-sounding “authoritative” explanations, like the most patronizing Victorian doctor imaginable—suggests that there may still be a market for that kind of approach.

About a hundred years ago, these ethical issues were carefully documented by a thoughtful native Canadian Indian called Quesalid. Quesalid was a skeptic. He thought shamanism was bunk, that it worked only through belief, and he went undercover to investigate this idea. He found a shaman who was willing to take him on, and he learned all the tricks of the trade, including the classic performance piece in which the healer hides a tuft of down in the corner of his mouth and then, sucking and heaving, right at the peak of his healing ritual, brings it up, covered in blood from where he has discreetly bitten his lip, and solemnly presents it to the onlookers as a pathological specimen, extracted from the body of the afflicted patient.

Quesalid had proof of the fakery, he knew the trick as an insider and was all set to expose those who carried it out; but as part of his training he had to do a bit of clinical work, and he was summoned by a family “who had dreamed of him as their saviour” to see a patient in distress. He did the trick with the tuft and was appalled, humbled, and amazed to find that his patient got better.

Although he continued to maintain a healthy skepticism about most of his colleagues, Quesalid, to his own surprise, perhaps, went on to have a long and productive career as a healer and shaman. The anthropologist Claude Lévi-Strauss, in his paper “The Sorcerer and His Magic,” doesn’t quite know what to make of it, “but it is evident that Quesalid carries on his craft conscientiously, takes pride in his achievements, and warmly defends the technique of the bloody down against all rival schools. He seems to have completely lost sight of the fallaciousness of the technique that he had so disparaged at the beginning.”

Of course, it may not even be necessary to deceive your patient in order to maximize the placebo effect; a classic study from 1965—albeit small and without a control group—gives a small hint of what might be possible here. The researchers gave a pink placebo sugar pill three times a day to “neurotic” patients, with good effect, and the explanation given to the patients was startlingly clear about what was going on:

The patients improved considerably. I could go on, but this all sounds a bit wishy-washy. We all know that pain has a strong psychological component. What about the more robust stuff, something more counterintuitive, something more…sciencey?

Dr. Stewart Wolf took the placebo effect to the limit. He took two women who were suffering with nausea and vomiting, one of them pregnant, and told them he had a treatment that would improve their symptoms. In fact, he passed a tube down into their stomachs (so that they wouldn’t taste the revolting bitterness) and administered ipecac, a drug that should actually
induce
nausea and vomiting.