The Placebo Disavowed:
Or Unveiling the Bio-Medical Imagination
From Hrobjartsson and Gotzsche’s interpretation, what becomes clear is that there exists a certain confusion between the two senses of the placebo effect. On the one hand, the placebo refers to a control device mobilized within clinical trials in order to provide both a standard of comparison and a means to insure objective assessment. As Bailar puts it: “Effective blinding may require the use of a placebo.” In this sense, the placebo is a procedural artifact introduced by a statistical mode of evaluation within which it negatively affirms the possibility of positively determining as a matter of “objective” knowledge the relation between the protocol being tested and the consequences that this protocol may or may not “cause.” Thus, by testing a protocol against the results of a non-treatment control, clinical studies make the positive determination of a causal relation between treatment and cure into a virtual “placebo effect.” On the other hand, this procedural use of the placebo gave rise to a secondary set of phenomena which, at least until Hrobjartsson and Gotzsche’s study, appeared to indicate that healing may take place independently of the specific protocols which the trials are designed to evaluate. The “placebo effect” here gestures towards a non-deterministic quantum of ameliorative agency which is recognized in the course of a study but which can not be reduced to the effects of the protocol under consideration. Extrapolating from this secondary phenomenon, some physicians sought to capitalize on this unexplained ameliorative capacity by expanding the notion of the placebo beyond the context of clinical trials to the treatment setting itself. The placebo effect freed from the confines of the clinical trial thus emerges to participate in the practice of medicine proper, albeit as a determinant bio-scientific protocol and hence one potentially subject to “objective” evaluation and falsification.
As laudable as this intended use of the placebo as treatment may be, it unfortunately contains within itself a paradoxical premise that troubles all its subsequent deployments. For, in seeking to transform unintended results observed within clinical tests--results that contradict the very deterministic premise upon which this testing is founded (i.e., that therapeutic effects are produced by fixed “causes” whose utility can be statistically evaluated)—into the basis for new clinical treatments, physicians necessarily if unwittingly engage one of the most vexing aporia of the bio-medical imagination. Indeed, as I will argue in this essay, one of the reasons the placebo effect has become so controversial for bio-science is that it functions as a fetish for “the imagination” that not only “blinds” researchers so that they can perform “objective” assessments of therapeutic protocols, but also literally blinds bio-medicine to the very assumptions upon which it is based. In other words, the placebo effect as it has been understood for the last fifty years occupies the place of an absence or lack of coherence in the domain of medical knowledge concerning the self-reflexive potential that human organisms have to participate in and to change the course of our own healing. Indeed, as we shall see below, it was precisely by appropriating this potential for its own ends and denouncing its significance for those whom it treats that scientific medicine began to consolidate its prestige and authority as the paramount model for healing in the West at the end of the eighteenth century. Not surprisingly, then, researchers have sought to cover up the scandal that the placebo effect manifests within contemporary bio-science either by denying its existence (or, at least, its statistical significance pace Hrobjartsson and Gotzsche) and folding it back into the nebulous domain of “the natural course of the disease,” or by transforming it into a instrument of medical practice itself. Hence, rather than simply representing a control device for medicine’s procedural self blinding, we might instead consider that the placebo constitutes one of medicine’s most glaring blind-spots.
One place to begin such a consideration is by noting that the history of the placebo effect is intimately connected to the history of bio-medical “progress.” As the story goes: Throughout the course of the nineteenth century, the scientific ideology of bio-chemical reductionism struggled to supercede various humoral and environmental explanations of disease, despite the fact that it offered no more viable treatment options than any of its less “scientific” competitors. However, at the end of the nineteenth century, in the wake of Pasteur’s famous vaccination experiments and the widely-heralded introduction of anti-toxins for tetanus and diphtheria, scientific medicine began to grounds its claims to epistemological superiority in the promise of specific treatments targeted to effect the course of particular diseases. The first decades of the twentieth century witnessed numerous attempts to develop new bio-chemical protocols for illnesses that heretofore had been untreatable (e.g., the use of Salvarsan for venereal diseases), though with somewhat limited success overall. As medical historian Roy Porter remarks: “Well into the twentieth century, for most infectious diseases there were no effective therapies; ancient and useless remedies like emetics were still prescribed.”[viii] This situation soon changed dramatically, first in the 1930s with the introduction of chemotherapies for streptococcal and pneumococcal infections, and then with the introduction of the antibiotic penicillin in the early 1940s, giving rise to a popular belief in medicine’s capacity to produce “magic bullets” against disease.[ix]
Unfortunately, not all potential treatments were uniformly effective or harmless, so medical researchers undertook to increase the safety and reliability of their treatment protocols, especially the pharmacological ones. In order to accomplish this goal, they developed new testing procedures designed to “objectively” guarantee the “truth” of the knowledge produced about therapeutic interventions. Researchers found that if they systematically introduced non-active controls into their studies they could more adequately specify the determinant results produced by the treatments under consideration. Furthermore, they decided that if they made themselves unaware of whether the agent they were testing was active or not, they could remove the taint of any subjective desire for the protocol to succeed on either the researcher’s or the research subject’s part. “Double-blind” methodologies, first introduced on an ad hoc basis during the 1930s and 40s, thus emerged as the gold standard of evaluation for new medical interventions from the late 1950s on. In these kinds of trials, the establishment of determinant causality for a specific treatment is predicated on the ability to statistically distinguish the effects of the treatment from the effects of a placebo given under similar conditions with the further proviso that those administering the trials do not themselves know which subjects are receiving placebos and which are not.
Ironically, even as double-blind testing produced increasingly reliable evidence about the efficacy of new treatment options (so much so that they became an essential part of the FDA approval process for new drugs) they also provided increasing evidence for the consistently positive therapeutic effects induced by the control elements themselves.[x] In 1955 the Harvard anesthesiologist Henry Beecher published a widely cited paper in the Journal of the American Medical Association, “The Powerful Placebo,” in which he affirmed: “It is evident that placebos have a high degree of therapeutic effectiveness in treating subjective responses, decided improvement, interpreted under the unknowns technique as a real therapeutic effect, being produced in 35.2+2.2% of the cases.”[xi] This often cited statistic, the very reference which Hrobjartsson and Gotzsche set out to debunk, seems to have underwritten a widespread acceptance of the ameliorative capacity produced by non-specific treatments. So much so in fact, that it not only lead to numerous attempts to explain the underlying physiological, cognitive, or psychological mechanisms that might account for such perplexing results (e.g., “conditioning,” “expectation, “ “desire,” “transference,” “placebo-genic personalities,” “opiate mediated pain modulation,” “psychoneuroimmunology,” etc.), but also to a revision of all of medical history. In retrospect, it seems, any successes achieved by earlier forms of medical intervention, or even by forms of healing that occurred in other cultural contexts, not verified by current bio-medical understandings could be explained as some manifestation of the “placebo effect.”[xii] Clearly, these forms of explanation act as supplements to a bio-medical orthodoxy that grounds its truth claims in an exclusive notion of bio-chemical causalities. They seek to account for any non-specific, non-reductionist amelioration of illness or suffering that occurs within the historical province of bio-medicine’s reign, as well as those that occurred temporally prior to or culturally outside of bio-medicine’s hegemony, in terms of the placebo’s non-determinant (or perhaps not-yet determinant) causality.
This expansive use of the “placebo effect” circumscribes curative techniques and practices not easily contained within bio-medicine’s prevailing modes of explanation. As such, it works to restrict the epistemological disturbances such healing engagements might introduce into the knowledge production that underwrites bio-medical practice. Instead of having to recognize, let alone appreciate, that other kinds of ameliorative agency may be grounded in different ways of making sense in and of the world, perhaps having their own specific forms of efficacy, the placebo concept allows bio-medicine both to diminish and to annex these alternative forms of healing agency for its own purposes. To designated a experience of healing as a “placebo effect” is not only to set it apart from the “real” domain of bio-chemical causality (while retaining the hope that some day a bio-chemical explanation may appear to account for this seeming deviation) but also to restrict the extent to which its existence can appear as a credible alternative to the deterministic claims of bio-medicine. Moreover, the implicit causality retained within the placebo designation maintains the giver rather than the receiver of the placebo as the active agent in the healing process, despite some limited recognition that “placebo effects [are] a subclass of self healing.”[xiii] Taken together, these interpretations defend advocates of bio-medicine against the recognition that they are not the only agents of healing, and moreover against the recognition that healing, whenever it occurs, occurs through the life process of the person who is ill—albeit with all the support and encouragement that their powerful and often life-saving resources have to offer.
In part, this misrecognition derives from the near-universal adoption of the metaphor “placebo” for the control element in clinical trials. Arthur Shapiro identifies the first example of this metaphorical equivalence in Torald Sollmann’s 1930 article “The Evaluation of Therapeutic Remedies in the Hospital”[xiv] which appeared in the Journal of the American Medical Association:
Apparent results must be checked by the ‘blind test,’ i.e., another remedy, or a placebo, without the knowledge of the observer, if possible. The placebo, if expectant treatment is permissible, also furnishes the comparative check of the natural course of the disease; comparison with another remedy helps towards a just perspective.[xv]
The introduction of “placebo” here designates what is assumed to be a non-active standard of comparison which concomitantly allows the “natural course of the disease” to display itself in the experimental context. Or, more accurately, the placebo constitutes an experimental artifact that instrumentally brackets human expectation by inertly fulfilling the desire for and anticipation of treatment and thereby produces within the experimental apparatus the “naturalness” of “the natural course of the disease.” However, prior to this affirmative clinical reinscription, the word placebo had served for the preceding century and a half to designate the boundary of scientific medicine by negatively characterizing the kinds of treatments offered by those whom medicine would denigrate as “charlatans” or “quacks.”[xvi] The history of this usage is somewhat circuitous: Derived from the future indicative of the Latin verb placere, to please, “placebo” was used to translate the opening word of Psalm 116:9 (Placebo Domino in regione vivorum—I will please the Lord in the land of the living) which was sung in the Vespers of the mediaeval church’s Office for the Dead and subsequently came to designate the Vespers itself. This “pleasing” aspect of the placebo was disaggregated from its ecclesiastical sense during the Middle Ages and came to mean flatterer, sycophant, or parasite—though perhaps continuing to carry with it some trace of mortality.
[viii] Roy Porter. The Greatest Benefit to Mankind: A Medical History of Humanity. New York: Norton, 1997. 452.
[ix] Alan Brandt. No Magic Bullet: A Social History of Venereal Disease in the United States Since 1880. New York: Oxford UP, 1985.
[x] On the history of clinical trials, see Arthur Shapiro and Elaine Shapiro. The Powerful Placebo: From Ancient Priest to Modern Physician. Baltimore: Johns Hopkins UP, 1997. 123-174. The literature on the placebo is copious. See for example: Daniel Moerman. Meaning, Medicine and the 'Placebo Effect.’ Cambridge : Cambridge University Press, 2002; Harry A. Guess, ed. The Science of the Placebo : Toward an Interdisciplinary Research Agenda. London : BMJ, 2002; David Peters, ed. Understanding the Placebo Effect in Complementary Medicine : Theory, Practice, and Research. New York : Churchill Livingstone, 2001; Howard Brody with Daralyn Brody. The Placebo Response : How You Can Release the Body's Inner Pharmacy for Better Health. New York : Cliff Street Books, 2000; Anne Harington, ed. The Placebo Effect: An Interdisciplinary Approach. Cambridge,MA: Harvard University Press, 1997; Michael Shepard and Norman Sartorius, eds. Non-Specific Aspects of Treatment. Toronto: Hans Huber, 1989; Howard Spiro. Doctors, Patients, and Placebos. New Haven: Yale University Press, 1986; Geoff Watts. Pleasing the Patient. London : Faber and Faber, 1992; Howard Brody. Placebos and the Philosophy of Medicine: Clinical, Conceptual and Ethical Issues. Chicago: University of Chicago Press, 1980; Michael Jospe. The Placebo Effect in Healing. Lexington, MA: Lexington Books, 1978;
[xi] Henry Beecher. “The Powerful Placebo.” Journal of the American Medical Association. 159 (1955). 1602-6.
[xii] Shapiro and Shapiro provides a classic example of this style of medical historiography.
[xiii] William Plotkin. “A Psychological Approach to Placebo: The Role of Faith in Therapy and Treatment.” In White, Tursky, and Schwartz. 245.
[xiv] Shapiro and Shapiro, 139.
[xv] Torald Sollmann. “The Evaluation of Therapeutic Remedies in the Hospital.” Journal of the American Medical Association. 94 (1930). 1280.
[xvi] Shapiro and Shapiro provide the most comprehensive etymology in their chapter “The Semantics of the Placebo,” 28-42.