The Placebo Disavowed: Or Unveiling the Bio-Medical Imagination

Ed Cohen

We especially need imagination in science.  It is not all mathematics, nor all logic, but it is somewhat beauty and poetry.
Maria Mitchell (1871)

The May 24, 2001, issue of The New England Journal of Medicine contained a provocative article by two Danish researchers Asbjorn Hrobjartsson and Peter Gotzsche entitled “Is the Placebo Powerless?”  Based on a meta-analysis of 130 clinical trials for a wide range of treatments (including pharmacologic, physical, and psychological protocols) that provided comparisons of  placebo with non-treatment results, the authors concluded: “We found little evidence in general that placebos had powerful clinical effects. . . .  Outside the setting of clinical trials, there is no justification for the use of placebos.”[i]  Proclaiming the “newsworthy-ness” of this conclusion, Gina Kolata, science correspondant for The New York Times, published a first section assessment of the responses to the article that began: “In a new report that is being met with a mixture of astonishment and sometimes disbelief, two Danish researchers say the placebo effect is a myth.”[ii]  While the characterization of the placebo effect as “myth” in order to distinguish it from “real science” might at first glance seem a consequence of poetic—or at least journalistic—license, it in fact recapitulates the frame offered by John C. Bailar III, M.D., Ph.D., in the editorial comment introducing Hrobjartsson and Gotzsche’s piece.  Pointedly entitled “The Powerful Placebo and the Wizard of Oz,” Bailar’s commentary opens with the following rhetorical gambit: “Some myths really ought to be true.”[iii]  Recasting as fiction an idea that had circulated as a scientific fact for the preceding half a century, Bailar preemptively disqualifies the placebo as “myth,” figuratively ostracizing it from the domain of bio-medical “truth.” He then succinctly describes what he takes to be the placebo’s main conceptual difficulty: “Is the improvement in patients given a placebo a result of the placebo itself, or of natural fluctuations in the progression of the disease, or of how the patient responds to the symptoms?”[iv] 

Differentiating among “the placebo” itself, “nature” (or “the disease progression”) itself, and “the patient” it/him/herself, Bailar asserts a set of necessary conceptual distinctions that the mythic placebo fails to maintain. This failure becomes problematic not simply because it introduces categorical confusion into the bio-medical schema, but also because this confusion makes it hard to know just who or what is acting when the placebo is in play. For bio-science causes must be singular and determinant if they are to count as “causes” at all. Thus, Bailar suggests, the underlying scientific problem with the placebo is that its effects (whatever they may be) cannot be uncategorically disentangled from ”the natural course of the disease” and therefore do not really count as “effects” at all. Of course, we might want to ask what ”the natural course of the disease” means here, given that whatever treatment or non-treatment protocol we’re considering takes place not only in the context of a clinical trial (which is not anyone’s idea of a “natural” setting) but also within a wider social context where a human response will always already be part of “the natural course of the disease.”[v]  Moreover, we might want to call attention to the evolutionary insight that much of human disease is a “natural” product of the co-mingling among humans and other organisms that we call “culture.”[vi] However, all this is somewhat beside the point. 

The real issue is: why does Bailar reassess the mystery of the placebo’s (non- or multi-determined) “effects” as being not very mysterious, much as the mystery of Wizard of Oz’s power was recast when “they found the curtain hid a very ordinary man”?  Furthermore, what is at stake in this seemingly incongruous if not ridiculous comparison between the placebo effect and the Wizard of Oz?  While Bailar’s invocation of this classic Hollywood tale might appear as merely a facetious literary device—further underscoring Hrobjartsson and Gotzsche’s interpretation of the placebo as simulacra, or perhaps even, to use the idiom of contemporary cinema, as “special F/X”—it actually reveals a crucial element of the placebo’s contradictory logic that itself remains hidden behind the curtain of this analogy. For, if we follow the filmic correspondence scrupulously, we recall that the Wizard disclosed behind the curtain at the control panel of his technical apparatus is not simply an “ordinary man.”  Rather, as the movie’s concluding frame discloses, the Wizard in both his “wizardly” and “ordinary” guises, like many of the characters that Dorothy encounters in Oz, is an dream figure generated from the persona of Dorothy’s waking life by her fevered imagination. This disappearance of Dorothy’s imagination from Bailar’s text is not, I will argue, just an oversight, or even an accidental  misreading of a classic movie for polemical purposes. Nor is my calling attention to this interpretive ablation merely an over-reading of a rhetorical trope that was merely introduced to provide some levity in an otherwise humorless academic essay. For the forgetting of the imagination marks by its very absence bio-medicine’s forgetting or even disavowal of “the imagination” itself--a forgetting or disavowal against whose recognition the placebo constitutes a defense. Given this more complicated scenario, where intra-diagetic figures are not always what they initially seem to be, we might then need to ask: What “wizardry” does the placebo manifest and why does it appear so scandalous to those who desire the certainties of bio-medical knowledge?

Of course, there are many concerns about the ethical use of placebos in clinical trials, especially where there are already effective treatment options available or where the risks of non-treatment are significant. For example, the numerous protests during the 1980s and 90s undertaken by ACT-UP and other advocates for people with AIDS against the clinical trial protocols stipulated by FDA for the approval of new drugs addressed precisely this risk.  More recently, the latest revision of the Declaration of Helsinki, while still contentious, has been rewritten to address some of these concerns, advocating only the use of active-controls in circumstances where known prophylactic, diagnostic , or therapeutic methods exist.[vii] Yet the controversy raised by Hrobjartsson and Gotzsche’s meta-analysis does not address these ethical aspects of the placebo at all; indeed, their conclusion remarks that clinical trials provide the only justifiable context for the use of placebo. Instead the issue they raise concerns only the statistical indistinguishability of the responses produced by placebos from the unadulterated course of the disease—with the begrudging caveat that there does seem to be some placebo efficacy as an alagesic for pain. In this context, the critique of the placebo is twofold: its aims to confound those who would use the putative “positive” or “healing” effects of the placebo to therapeutic ends (except possibly in the murky domain of pain management) and moreover to deny that the “placebo effect” is even statistically significant enough to acknowledge as an effect in the first place.  

[i] Asbjorn Hrobjartsson and Peter Gotzsche. “Is the Placebo Powerless? An Analysis of Clinical Trials Comparing Placebo with No Treatment”  New England Journal of Medicine 344 (2001): 1594-602.

[ii] Gina Kolata, “Placebo Effect is More Myth than Science, Study says.” New York Times, May 24, 2001. A 20.  Also, Gina Kolata. “Putting Your Faith in Science?” New York Times, May 27, 2001.  4:2.

[iii] John Bailar. “The Powerful Placebo and The Wizard of Oz.” New England Journal of Medicine 344 (2001): 1630-1632.

[iv] Bailar, 1631.

[v] This is a basic premise of most medical anthropology. See for example: Lola Romanucci-Ross, Daniel E. Moerman, Laurence R. Tancredi, eds. The Anthropology of Medicine : From Culture to Method.  Westport, Conn. : Bergin & Garvey, 1997.  For a few examples within the literature on the placebo, see David Morris, “Placebo, Pain and Belief: A Biocultural Model.” In Anne Harrington, ed., The Placebo Effect: An Interdisciplinary Exploration. Cambridge: Harvard UP, 1997.  187-207; Robert Hahn. “A Sociocultural Model of Illness and healing.” In  Leonard White, Bernard Tursky and Gary Schwartz, eds. Placebo: Theory,  Research, Method. New York: The Guilford Press, 1985.167-195.

[vi] On the evolution of disease, see William McNeill.  Plagues and People. New York: Anchor Press, 1976.  Also on contemporary manifestations, see Manuel De Landa. “Flesh and Germs.” A Thousand Years of Nonlinear History. New York: Swerve Editions, 1997;  Laurie Garrett. The Coming Plague: Newly Emerging Diseases in a World Out of Balance.  New York: Farrar, Strauss and Giroux.  1994.

[vii] Ezekiel Emanuel and Franklin Miller. “The Ethics of Placebo-Controlled Trials—A Middle Ground.” New England Journal of Medicine 345 (2001): 915-919.

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