The Yale Journal for Humanities in Medicine

The Placebo Disavowed: Or Unveiling the Bio-Medical Imagination
(continued)

Ed Cohen
edcohen@rci.rutgers.edu

Following Bruno Latour, who admonishes us that "we have never been modern," however, I want to suggest that "modern" bio-medicine has never fully modernized insofar as it has never successfully bracketed the imagination from its practices.[xlv]  Furthermore, just as Latour suggests that modernity can only manifest the exclusionary calculus of “purification” by which it seeks to separate society from nature, humans from non-humans, or individuals from society, though the multiplication of "hybrids" that partake of both, I would like to suggest that medicine can only purify “the imaginary” and “the material” as ontologically distinct through its largely unappreciated reliance on the placebo as a “translation” between the them.   When medicine began to invoke the placebo as an illegitimate, a.k.a. “non-medical,” form of healing at exactly the same time that the Royal Commission was debunking the effects of Mesmerism (remember the first known medical use of “placebo” was in 1785, the year after the Commission’s report appeared) it did so by specifying a placebo’s illegitimacy not as a sign of its lack of efficacy but as the “pleasing” materialization of a non-determinant cause.  In order to produce this discriminatory specification, however, medical authorities necessarily invoked their own imagination about the imagination, and especially about its radical distinctness from the material. They thereby effaced the materiality of their own imaginary intervention, corporealized in the very institutional discourses and practices founded on this conceptual distinction.   Thus, rather than having ever actually been excluded from medical rationality, the imagination simply passed from being an undesirable attribute of the objects of bio-medical inquiry to being an essential though unacknowledged tool for its subjects.

By offering this genealogical frame for recent controversy concerning the placebo effect, I hope in part to help revalue and therefore appreciate the work of the imagination which has never been absent from medicine.  Certainly, no one would want to claim that bio-medicine lacks imagination.  All of the classic accounts of therapeutic breakthroughs from Jenner to Lister to Pasteur to Watson and Crick emphasize the “genius” that enabled their reinterpretation of empirical evidence to new ends.  Indeed, even the accounts of the daily experiences of a general practitioner  routinely link the “art” and “science” of medicine.  However, for the last two hundred years the role of the imagination has been subordinated to the logic of determinate causality (as if this were not itself a particular historical manifestation of the imagination) both for the practitioners of scientific medicine and for their clients.  When in the course of the Twentieth Century the effects of the imagination began to reassert themselves within the very “double-blind” testing protocols designed to produce and reproduce the truths of bio-scientific rationality, they were quickly, if contentiously, appropriated for (or disavowed by) bio-medicine as manifestations of the “placebo effect.”  Yet what the ameliorative potential of the placebo reveals—even if it only obtains as an analgesic for pain or even if it only works for a very limited subset of individuals—is that the imagination may have the capacity to inform the materiality of the human organism on a molecular and cellular level. 

Certainly, the founding of the Office for Alternative Medicine in 1992,  or the establishment of the National Center for Complimentary and Alternative Medicine in1998,  under the auspices of the National Institutes of Health marks somewhat of a sea change in official understandings about the potential that non-allopathic treatments offer.[xlvi]  Moreover, recent articles in bio-scientific publications on techniques like bio-feedback for high blood pressure, chronic pain, migraines, incontinence,  and constipation, or on the use of guided imagery for numerous conditions including cancer, asthma, arthritis, coronary disease, diabetes, fibromilagia, headache, and inflammatory bowel disease, among others, along with considerations of such practices as journal keeping and creative writing as therapeutic modalities, suggest that there exists some practical recognition of the imagination as a resource for healing--even if large commitments of resources have not always followed from this recognition.  (Not surprisingly, much of the interest in these techniques appears in the highly gendered domain of nursing, along with the slightly less gendered domains of psychotherapy and psychiatry.)  No matter how marginal they remain with respect to the vast and highly funded arena of bio-chemical bio-medicine, however, these technologies gesture towards the possibility for freeing the imagination from the confines of the placebo and reintroducing it to medicine as a resource in its own right.   While I think it would be wonderful if bio-medicine could begin to acknowledge the limitations of its determinist epistemology which are deeply embedded in its history and open its arms in welcome to new “imaginary” technologies that have been previously excluded, I’m not really holding my breath.  Indeed, what I take to be the most promising possibility raised by my attempt to recall the imagination from its exile outside the bio-medical domain lies with those of us who are the consumers of bio-medicine. 

     For example, rather than debunking the placebo as a myth, it might be time to suggest that there is no need to abjure “pleasure” as a degradation of scientific principles and that medicine might well want to adopt an “ethic of pleasing” as one of its most valuable assets.  Offering an explicit appeal to a patient’s desire (instead of covertly denying and disavowing its existence in the name of a “scientific” practice) might open up a collaborative dynamic in which  we could begin to investigate more creative and effective ways to invoke the human imagination to healing ends.  Given the large amounts of money that Americans currently spend out of their own pockets for various forms of “alternative” healing practices—conservatively estimated at $27.0 billion in 1997, the same amount spent out of pocket on all US physician services--it appears that there is already a marked and market recognition on the part of U.S. consumers of some insufficiencies in the bio-medical paradigm.[xlvii]  Yet by and large bio-medicine continues to dismiss or ignore the implications of these alternatives to its own orthodoxies, or at the very least to confine them within the supplemental categories “alternative” or “complimentary,” implicitly holding them to be contemporary forms of what their nineteenth-century counterparts would have dismissed as “placebos.”  Clearly, a lot of us don’t agree with this assessment and have taken our bodies and our dollars to the very placebo purveyors that medical science has been warning us against for the last two hundred years.  More than just a matter of consumer choice, our decisions to patronize non-medical healing practitioners suggest that bio-medicine’s hegemony over American health care is losing some of its purchase.   Indeed, it might even be a sign that we are in the process of reclaiming our imaginations as a healing resource (even insofar as we are imagining that bio-medicine is not the only credible healing regime) from the oblivion to which scientific  medicine has sought to consign them for the past two centuries or so.  For we should remember that it is only the imagination of those who seek healing that has been ostracized from the bio-medical pantheon, not that of those who claim to be the authorized agents of healing.  The recent disavowal of the placebo effect by Hrobjartsson and Gotzsche  might ultimately prove most useful, then, in helping us understand that the imagination does not need to be and has never actually been exiled from medical practice.   For, the placebo, as it has come down to us, always already situates determinism as the privileged form of biological causality, rendering all other options somehow less real and less true.  Perhaps by noticing that the placebo effect marks a blind spot within the ways scientific medicine has made the world visible and intelligible for the last two centuries, we can not only begin to recognize but also appreciate that the bio-medical imagination does not and need not function only when veiled.

Published: November 26, 2002

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