PLACEBO DEFECT

John S. Haller Jr, Shadow Medicine: The Placebo in Conventional and Alternative Therapies. Columbia University Press, 2014.

The author states his position clearly in the Introduction. His aim is ‘not to lay waste [to] one side or the other in the ongoing feud between the proponents of evidence-based medicine and those supporting unconventional therapies’, and on the whole his objectivity is indeed remarkable, especially for a field that is infamous in its high emotional reaction and indeed academic vendettas.
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It is especially good on the history of medicine, whose emergence into anything approaching efficacy is startlingly recent. What it is not so good on is the actual subject of the book – i.e. coming to grips with the major questions that surround the mystery of the placebo.

True, we learn how the placebo emerged as a force to be reckoned with. For example, Haller examines the role of landmark books, such as Harry K. Beecher’s 1955 work The Powerful Placebo in establishing the phenomenon as worthy of study, noting ‘the placebo threatened the very foundation blocks supporting the edifice known as conventional medicine’.

If it threatens allopathy, what is the placebo’s role in the more elusive and emotive world of alternative medicine? Some would say unhesitatingly that the placebo is alternative medicine, providing the only plausible explanation for any cures that might happen, almost accidentally. But Haller is more open and much more generous, devoting many pages to an examination of the differences (many) and the similarities (few) between the two camps of healers. Sceptics might wonder, simply, why bother? The answer is, briefly, that at least half of all Americans use not only an alternative treatment – one of the myriad on offer – but specifically the one area that evidence-based research has repeatedly shown to have the least going for it. Yes, 50 per cent of Americans actually use homeopathy: so in a market that is resolutely consumer-driven, it must, therefore, be taken seriously. And it certainly is here – not in the sense that Haller is intrinsically or overtly biased in favour of homeopathy, but because it basically takes over the second half of a rather short book. (A third of the pages are devoted to notes, references, bibliography, appendices and the index: in itself this might be laudable and indeed very helpful to other researchers, but the main discussion has no room to enlarge.)

Determined as ever to be balanced and fair, Haller goes into the huge and ongoing row about the efficacy of homeopathy in some detail, sometimes too much and too repetitively. He notes that the whole realm of alternative medicine operates from entirely different perspectives from the mainstream, taking on board patients’ emotional, social and spiritual backgrounds and seeking to deal with their problems through the manipulation of non-physical elements, such as energy matrices. While never straying into card-carrying believer territory – it really isn’t that kind of book, being designed for health professionals – Haller does make several trenchant points about homeopathy. Perhaps the most significant is that, while routinely sneered at as finding ‘the common diagnostic category’ irrelevant, the fact is that given its modest apparatus and actual medicine – mostly treated water, after all - there is little economic incentive to develop or encourage homeopathy, unlike conventional medicine’s notoriously intimate relationship with Big Pharma.

But trial after trial has been unable to find much that is conclusive about just how homeopathy works. Because the problem is, apparently it does. But how? Is any benefit from this and other alternative therapies simply all in the mind? Most allopaths believe it is. Haller quotes medical expert Michael Kottow: ‘alternative approaches bathe themselves in the self-fulfilling prophecy that he who believes in his own cure will actually get better.’ (Yes, but don’t regular GPs routinely use sugar pills?)

Haller does a sound job telling the often surprising story of the discovery and implementation of the placebo (from the Latin ‘I go before’). We discovery that considerable proportions of various trial patients’ conditions have always improved through the administration of such placebos as saline solutions or sugar pills. Once considered totally inert, now they are seen as an active part of the therapy, though the ethical arguments rumble on. Is ‘employing a lie to heal’ what professionals really should be doing? (Surely if it’s a contest between a doctor not ‘lying’ about the ingredients of the pills and us not getting better, and a doctor either implicitly telling a fib or being evasive about the pills and us making a recovery, then most of us know which side we’d be on.)

We also learn that the doctor him/herself can be seen as a drug, what used to be called 'bedside manner’ still being a significant factor in the progress of patients. Of course this is where most fans of alternative therapies usually find the most potent attraction – in the practitioners themselves, who are willing to spend time on discovering as much as they can about the patient, and are not afraid to empathise openly. (The contrast is possibly more glaring in the UK, where harassed NHS doctors can seem uncaring and are usually very rushed. Of course their services are free. Alternative therapies are private, and therefore one is always paying for more time and attention.)

Not surprisingly in a book such as this, comments such as the following point up the argument: ‘the real challenge for researchers is to better understand the power of the placebo.’

Well, quite.

This might be a meticulously researched, soberly ordered and objectively argued work. It has many admirable qualities and as a reference work on several aspects of the history of medicine – in theory and practice – and on the intricacies of the great divide between conventional and unconventional therapies it is excellent. And it must be said, in the most literal way Haller does fulfil the promise implicit in the subtitle. He does indeed examine the placebo in both conventional and alternative medicine. But surely there should be much, much more to the discussion than that.

Unfortunately we learn next to nothing about the workings of the placebo. In an almost throwaway line about its power, Haller mentions the placebo’s track record in curing warts. He then fails to follow up on this, which is perhaps a missed opportunity, as this highlights one of the main elements of the placebo mystery.

As we all know, warts are very real, unsightly little lumps. There they are, on one’s hand, say, and are therefore clearly not a figment of one’s imagination. Yet certainly in the past older family members, local ‘wise women’ or even old-school GPs have gone through the ritual of removing the wart at a distance through some apparently meaningless little ritual. And the very real wart has obediently disappeared, never to return. Witchcraft? Well in one sense perhaps, but put in modern terms it is ‘simply’ the placebo effect. Aches and pains are one thing – extremely hard to quantify, even for the sufferer – but a wart is unarguable. Yet it goes because we believe it will, apparently thanks to a mixture of authority and ritual. To the placebo effect. But how exactly?

Not once in this entire book does the author address the burning question of the actual mechanics behind the placebo effect. He never trawls though the literature of autosuggestion/suggestion, for example, where he would find the early days of extreme hypnosis packed with material with an immediate relevance to the subject of his book. Not only were people cured of dire skin conditions by the power of suggestion – or hypnosis – but in the pre-litigious and pre-politically correct days it was repeatedly demonstrated that if a hypnotised subject were told s/he would feel the mere touch of a cold glass rod but actually a red-hot poker were applied to their skin, they would suffer neither pain nor burn. Often there was not even any reddening of the skin. But does this sort of phenomenon echo or even explain the placebo effect? Sadly there is no information on such matters in this book.

Also although never dwelt on by Haller, homeopathy is frequently used by vets, who report that all sorts of patients – dogs, cats, birds, donkeys – often benefit enormously from the treatment. What kind of placebo could possibly be at work in those cases? Is it possible that the placebo effect can be felt as it were at second hand, through the owners?

(One is reminded, too, of the famous British alternative healer Mathew Manning whose reputation was such that he was invited to address London’s Royal College of Surgeons in the 1980s. At question time he faced much professional contempt as doctor after doctor accused him of ‘just using the placebo effect’. ‘Well,’ said Manning, ‘If it’s so easy why don’t you do it?’)

Shadow Medicine is a very sound, carefully academic work, erring on the side of wordy worthiness. It’s not an easy read and occasionally lapses into downright dullness, which in itself might deter many who are excited by the questions surrounding the placebo phenomenon. But stylistic considerations aside, it simply stops far too short. Understanding the placebo effect could lead to huge leaps in our understanding of illness and wellness – not to mention human consciousness - but sadly, despite the author’s heroic efforts, this is not the book that will do it. Perhaps Haller might consider a sequel, in which the placebo itself is the star? 

• Lynn Picknett.