What’s the Problem With a Good Placebo?

I have a cold this week and my back hurts again. I hate being sick and I don’t suffer well, but sooner or later this is what life holds in store for each of us. It’s said there’s no avoiding death and taxes, and both are sure to go up with the spiraling cost of health care and the aging of the boomers.

More and more people are dissatisfied with health care in the United States. According to a 2009 NIH study, Americans spent $34 billion on complementary and alternative medicine (CAM), accounting for 11.2 percent of total out-of-pocket expenditures on health care. Is this wasted money? Does prayer heal? Does homeopathy work? Is acupuncture effective? Is Ayurvedic medicine really medicine at all? And what should I do about my lower back pain and stuffed up nose?

Most physicians trained in modern scientific medicine are quite skeptical of CAM and other spirituality-based healing practices, but contemporary research points increasingly to what we might call the deep semiotics of health. It seems, minimally, that hope helps to heal. And ritualized hope in groups heals more effectively.

Recognizing the Signs and Symbols of Health

Semiotics, of course, is the study of signs and symbols, but it really has nothing to do with the fictional “symbologist” character played by Tom Hanks in Dan Brown’s The Da Vinci Code. Semiotics is mostly dense philosophy and linguistics with a dash of neuroscience thrown in.

The deep semiotics of health is an attempt to recognize the signs and symbols of health and to take control over the largely unconscious processes that affect our minds-brains-bodies. The mash-up of these terms is necessary in light of contemporary science. Let me explain.

Psychosomatic effects are involved in all medical therapies, whether they are orthodox scientific or alternative healing practices. There are now several decades of placebo studies to validate this fact, including measurable biochemical responses in subjects; most notably in releasing endogenous opiates in the brain for pain relief.

To these we can add new insights about how our mental states can influence our immune systems and regulate powerful hormones in our bodies. Too much mental stress, for instance, releases cortisol in our bloodstream—a powerful steroid that, over time, weakens our immune system.

Psychosomatic effects are not really isolated in individual patients, as physicians tend to assume: a better term instead might be psycho-social somatic effects. Try saying “psycho-social somatic effects” ten times fast with a runny nose—keep the tissues handy.

Epidemiological studies and mathematical models of “social contagion” further reveal that positive and negative behaviors and attitudes, including many indicators of physical health, can travel indirectly through communities and social networks, though we don’t actually understand how this happens.

These effects only work because of complex social and cultural interactions over the course of a lifetime. Popping pills, white coats, stethoscopes, and the examination room are all symbols in the liturgy of sickness and healing. They’re reinforced from childhood with the rituals of visits to doctors and pharmacists, the act of taking pills at home, and television medical dramas from Doctor Kildare to ER. In Chinese culture, acupuncture is similarly reinforced and encoded as effective therapy. Antibiotics, and apparently also acupuncture, work regardless of your belief system—but they work better if you believe in them.

Double-Blind

The history of medicine up until the last century was essentially the history of the placebo effect. Double-blind, randomized control trials are now the gold standard in medical research and have only been widely used for the last fifty-odd years. It is a research protocol that works especially well for pharmaceutical products where taking a pill or an injection is the intervention, but designing such studies for acupuncture, chiropractics, or even back surgery is no easy matter. Double-blind experiments have blinded researchers to the profoundly psychosocial somatic dimensions of human health.

Calling something a placebo, in turn, is widely perceived to be a criticism or even an insult in the contemporary research climate; but there is nothing wrong with a good placebo, especially when you choose it yourself. The cup of herbal tea I’m drinking may have no pharmacological effect: I might just as well drink hot water. But the herbal aroma sure makes me think and feel like I am getting better.

Placebos may be the most effective and important tool in any healer’s toolbox, though they certainly raise complex medical and ethical problems. Informed consent, for instance, should still guide medical ethics. Substituting sham treatments for an effective, known treatment for a serious illness is always out of bounds. The good news, however, is that patients can and should be informed about the benefits of a holistic approach that includes CAM and other spiritually-based interventions of their own choosing. These should be seen as a supplement to known effective treatments developed by scientific medicine. I still plan to take NyQuil tonight. But, now, CAM healing deserves to be taken seriously as part of the mix.

Spiritual healers and CAM practitioners don’t think of themselves as mere placebo providers. These practices have been developed over thousands of years of human experimentation in diverse cultures. There may be scientific reasons why some of these CAM therapies work, just as some of what is practiced under the rubric of Western, physicalist medicine is not really evidence-based, but an ongoing experiment with only probabilistic results and unknown longterm consequences.

There may be some important discoveries for science to sift out from the enormous diversity of traditional medications and procedures. Hot baths, extra sleep, and chicken soup all turn out to have explainable benefits for my current condition, for instance. The impact of much of CAM, however, is partially, probably, and perhaps predominantly psycho-social somatic—but so are all medical therapies, to varying degree, including my blue-green, foul tasting NyQuil. In cases where physicalist medicine offers no cure for chronic and life-threatening illnesses, CAM therapies and their spiritual cousins do provide at least a kind of relief for suffering patients, and maybe much more.

The More Elaborate the Ritual, the More Effective the Placebo

Is there a way to systematically individualize, ritualize, and harness psycho-social somatic interventions as a supplement to standard treatments? This would require clinicians to customize the context of health care to the culture and beliefs of each particular patient. They could also try to utilize larger social networks as part of the intervention for the patient; both inside the medical institution and outside, among the patient’s friends and family. The wisdom of CAM and spiritual interventions is that the more elaborate the healing ritual, the more effective the placebo effect. Supplementing physicalist medicine in this holistic way might improve health outcomes by thirty percent or more if placebo studies can be generalized and averaged out across disease types.

The best medical science is now supplemented by the wisdom of the ages—wisdom which also turns out now to have at least some scientific basis. The ancient physician Galen noted “He cures most successfully in whom the people have the most confidence.” Even the modern CAM debunker Barker Bausell curiously ends his book, Snake Oil Science, by advising his readers on how to select a placebo therapy that works. “Once you’ve started the therapy,” he writes, “embrace it… with all your heart and soul.” After three days of blowing my nose and feeling lousy, I might just try some of that snake oil.

Leave a Reply

Your email address will not be published. Required fields are marked *