EFTA02695679.pdf

woman's ovaries: he told me, still looking ANNALS OF SCIENCE mystified, thirty-five years later. "It had to be some kind of placebo, but I had never given the idea of a placebo effect much a THE POWER OF NOTHING tention. I had great respect for shamans— and I still do. I have always believed there Could studying theplacebo effect change the way we think about medscine? is an important component of medicine that involves suggestion, ritual, and be- BY MICHAEL SPECTER lief—all ideas that make scientists sacam. Still, I asked myself; Could I have cured her? How? I mean, what could possibly have been the mechanism?" At the time, few serious scientists would have entertained such questions, let alone allowed words like "ritual" and "belief" to seep into a conversation about medicine. Placebos had a bad name, which is not surprising, since they have been used primarily to deceive people. In clinical trials, if a drug and a sugar pill produce similar results, the drug has gem erally been considered worthless. But the definition of medical treatment is chang ing, and so arc attitudes about placebos. This year, Harvard created an institute dedicated wholly to their study, the Pro- gram in Placebo Studies and the Thera- peutic Encounter. It is based at the Beth Israel Deaconess Medical Center and Kaptchuk was named its director. He has already recruited leading researchers from around the world, in disciplines as diverse as neuroanatomy and semiotics. The program was formed to explore an idea that even twenty years ago would have seemed preposterous: that place- bos—given deliberately—might be de- ployed in clinical practice. As medicine. Kaptchuk has no shortage of critics. or years, Ted Kaptchuk performed he said. "It was a different place then." They acknowledge the power of the F acupuncture at a tiny clinic in Cam- Not long after Kaptchuk arrived in bridge, a few miles from his current Boston, he treated an Armenian woman mind to influence health but question the rigor of studies suggesting that pla- office, at the Harvard Medical School. for chronic bronchitis. A few weeks later, cebos could possibly prove as valuable as He opened for business in 1976, on a she showed up in his office with her hut drugs. Indeed, the idea of dispensing street so packed with alternative healers band, who had a Persian rug slung over sugar pills is jarring even to those who, that it was commonly referred to as his shoulder. He nodded to Kaptchuk and like Kaptchuk, are enthusiastic about it. "quack row." Kaptchuk had just returned said, 'This is for you." Kaptchuk accepted After all, placebos have almost always from Asia, where, as an exiled alumnus the rug, which he still owns, but had no been defined as exactly what medicine of the turbulent sixties, he had spent four idea what he had done to earn it. "Oh, is not. "I realized long ago that at least years honing his craft. "There were lots doctor, you have been so wonderful," the some people respond even to the sug- of alternatives on that street in those woman told him. "You cured me. I was gestion of treatment," Kaptchuk said. days, but no practitioners of Chinese about to have an operation on my ovaries "We know that. We have for centuries. medicine," Kaptchuk, who is sixty-four and the pain went away the day you saw But unless we figured out how that pro- and still lives in the neighborhood, told me." Kaptchuk never spoke to the woman cess worked, and unless we did it with me recently as we sipped (Chinese) tea again, but he has been unable to get her data that other researchers would con- in the study of his house. "The area is a out of his mind. 'There was no flicking sider valid, nobody would pay attention little too L L. Bean for my taste now," way needles or herbs did anything for that to a word we said." 5 The research has been propelled in Scientists are now seriously investigating—and debating—our response to sugar pills. large measure by the emerging discipline 30 TIE NEV YORKER. DECEMBER IP. 201 EFTA_R1_02046876 EFTA02695679 of neuroimaging—which, like a live sat- and we will see where the research lands." ellite feed from inside the human body, Kaptchuk practiced acupuncture for permits scientists to track precisely how half his adult life. But he stopped twenty a person reacts to a drug (or a placebo) as years ago. Despite the popularity of acu- soon as he takes it. An injection of saline, puncture, clinical studies continually fail for example, that has been described as a to demonstrate its effectiveness—a fact drug not only will reduce symptoms of that Kaptchuk doesn't dispute. I asked Parkinson's disease but can help a pa- him how a person who talks about the tient produce more of the dopamine that primacy of data and disdains what he the disease destroys. Results like those calls the "squishiness" of alternative med- have provided scientists with chemical icine could rely so heavily on a therapy evidence of something they had long with no proven value. Kaptchuk smiled suspected: simply believing in a treat- broadly. "Because I am a damn good ment can be as effective as the treatment healer," he said. "That is the difficult itself. In several recent studies, placebos truth. If you needed help and you came have performed as well as drugs that to me, you would get better. Thousands Americans spend millions of dollars on of people have. Because, in the end, it each year. isn't really about the needles. Its about Transforming interesting laboratory the man." findings into medicine is never simple, however, particularly when those find- ar most of human history, placebos ings involve fake pills and sham in - F were a fundamental tool in any phy- jections. Some people clearly respond sician's annamentariwn—tarmetimes the better to placebos than others, though only tooL When there was nothing else we don't know why; some illnesses and to offer, placebos were a salve. The word afflictions are more amenable to sugges- itself comes from the Latin for "I will tion than others; and many of the most please." In medieval times, hired mourn- intriguing findings are tenuous. Even so, ers participating in Vespers for the Dead the recent research is difficult to dismiss. often chanted the ninth line of Psalm Through conditioning techniques, for 116: "I shall please the dead in the land example, our brain can learn" different of the living." Because the mourners were kinds of placebo effects: people first given hired, their emotions were considered in- morphine and then a placebo have one sincere. People called them "placebos." neurochemical response, while people The word has always carried mixed who take ibuprofen followed by a pla- connotations. Thomas Jefferson wrote cebo have another. Different "doses" approvingly of what he called a "pious cause different reactions, and studies fraud," and noted that "one of the most have demonstrated that people who successful physicians I have ever known suffer from headaches and consume as- has assured me that he used more bread pirin regularly can associate the shape, pills, drops of coloured water, and pow- the color, and even the taste of a pill with ders of hickory ashes, than of all other a decrease in pain. The value of treat- medicines put together." But, as increas- ments like those—which have none of ingly specific knowledge about human the side effects of drugs—would be ism anatomy emerged, people began to de- mense, but placebos are not pharmaceu- mand scientific answers to medical ques- ticals, and no reputable researcher has tions. Knowledge displaced faith, and suggested that they will soon be for sale human health improved rapidly. Antibi- at your local pharmacy. otics are real; placebos are not Kaptchuk acknowledges that place- The first publicly acknowledged pla- bos are not magic potions. "Placebos cebo-controlled trial—and still among don't shrink tumors," he said. "They the most remarkable—took place at the don't make blind people see. If you are request of King Louis XVI, in 1784, paralyzed, they won't help you walk." He under the direction of Benjamin Frank- deplores the grandiose claims of alterna- lin, then the American Ambassador to tive medicine and prefers to rely on data. France. The German physician Franz "Ultimately, I am not a zealot or even a Anton Mama had become famous in true believer," he said. "I am sure that I do Vienna for a new treatment he called not understand the placebo effect. I ask "animal magnetism," and he claimed to questions, hopefully valuable questions, have discovered a healing fluid that 7HE NEW YORKER. DECEMBER IP. 201 PI EFTA_R1_02046877 EFTA02695680 could "cure" many ailments. Mesmer Powerful Placebo," in which he wrote significant reduction in pain. People re- became highly sought after in Paris, that "placebos have a high degree of thcr covering from dental surgery were told where he would routinely "mesmerize" apcutic effectiveness in treating subjec- that they were about to receive a dose of his followers—one of whom was Marie tive responses." The paper has been cited morphine, saline, or a drug that might Antoinette. The King wasn't buying it, more than a thousand times by other sci- increase their pain. By then, researchers however, and he asked a commission of entists, and Beecher's conclusion—that had learned not only about the nocebo the French Academy of Sciences to the placebo effect plays a critical role effect but that a suggestion of relief will look into the claims. (The members in- in almost any medical intervention— often trigger the production of endor- cluded Franklin, the chemist Antoine influenced much of what has followed in phins, so they were not surprised that pa- Lavoisier, and Joseph Guillotin—who clinical research. His basic supposition tients receiving saline reported reduced invented the device that would eventu- was correct emotions and expectations pain. ally separate the King's head from his can affect our perception of pain. What came next, however, funda- body.) The commission replicated some Before Beecher's work, new drugs mentally reshaped the field. The re- of Mesmer's sessions, and, in one case, were tested in a haphazard manner, since searchers dismissed the subjects who re- asked a young boy to hug magnetized then, they have always been compared ceived morphine and then divided the trees that were presumed to contain the with a placebo or with another drug. But remaining participants into those who healing powers invoked by Mesmer. He Beecher's methodology was deeply responded to the placebo and those who did as directed and responded as ex- flawed. Although he reported that place- didn't. Then they introduced Naloxone pected: he shook, convulsed, and bos were effective more than a third of into patients' I.V. drips. Naloxone was swooned. The trees, though, were not the time, he shrugged off a phenomenon developed to counteract overdoses of magnetic, and Mesmer was denounced known as "regression to the mean." Over heroin and morphine. It works essen- as a fraud. Placebos and lies were inter- time, the condition of most patients tially by latching onto, and thus locking twined in the public mind. improves, with or without treatment. up, key opioid receptors in the central It was another hundred and fifty years A person who enrolls in a clinical study nervous system. The endorphins that we before scientists began to focus on the when he is feeling particularly bad is secrete attach themselves to the same re role that emotions can play in healing. likely to improve solely as a result of the ceptors in the same way, so Naloxone During the Second World War, Lieu- natural course of the illness, not because blocks them, too. The researchers theo- tenant Colonel Henry Beecher—who he was given a placebo. (And people rized that, if endorphins had caused the went on to become the first chairman of often enroll in such studies when they are placebo effect, Naloxone would negate the anesthesia department at Massachu- sickest.) A patient who knows that he is their impact, and it did. The Naloxone setts General Hospital—attempted to in a study also may expect a better then caused those who responded positively to assess the degree to which the severity pcutic result than one who doesn't. Ifyou the placebos to experience a sharp in- of a soldier's injuries corresponded to believe that doctors are particularly atterr crease in pain; the drug had no effect on the amount of pain he felt. In Europe, Live, you can get better more rapidly, even the people who did not respond to the Beecher met with more than two hun- if they aren't This is known as the Haw placebo. The study was the first to pro. dred soldiers, gravely wounded but still thorne effect. (There is also a "noccbo vide solid evidence that the chemistry be- coherent enough to talk; he asked each effect." Expecting a placebo to do harm hind the placebo effect could be under man if he wanted morphine. Seventy- or cause pain makes people sicker, not stood—and altered. five per cent declined. better. When subjects in one notable "It was one of those studies that make Beecher was astounded. He knew study were told that headaches are a side the scales fall from your eyes," Kaptchuk from his experience before the war that effect of lumbar puncture, the number of told me. "I had just started to think about civilians with similar injuries would have headaches they reported after the study the placebo effect—scientifically and his- begged for morphine, and he had seen was finished increased sharply.) torically. And here comes this paper that healthy soldiers complain loudly about For years, researchers could do little says that, even if it's all in your head, there the pain associated with minor inconve- but guess at the complex biology of the is still a biological mechanism driving niences, like receiving vaccinations. He placebo response. A meaningful picture these reactions. It was very exciting." concluded that the difference had to do began to emerge only in the nineteen- with expectations; a soldier who survived seventies, with the discovery of endor- aptchuk assumed that the results a terrible attack often had a positive our phins: substances secreted in the brain 11 would add legitimacy to the field. look simply because he was still alive. that arc chemically similar to opiates like He was wrong. 'Things are better than Beecher made a simple but powerful ob- morphine and heroin. The discovery led they were," he said. "But even now, you servation: our expectations can have a to the novel idea that, in effect, the brain know, people at Harvard talk about pla- profound impact on how we heaL produces its own pharmacy. In 1978, cebos the way the Popes used to talk Armed with this information, and three scientists from the University of about medicine. They declared that Jews with his conviction that the placebo California at San Francisco—Jon Levine, were not allowed to treat Christians— effect could be harnessed to help relieve Newton Gordon, and Howard Fields— not because they were not good doctors suffering, Beecher returned to the United decided to investigate whether endor- but because it would have been ethically States and continued his research. In phins might explain why patients who wrong. These are ethical judgments mas- 1955, he published an article called 'The received placebos often reported a querading as science. Because from the 32 TEE NEV DECEMBER E. 201 EFTA_R1_02046878 EFTA02695681 beginning I kept having this nagging found, for example, that diazepam— suffering from irritable-bowel syndrome thought: what is so bad about getting more commonly known as Valium—has were not deceived about their treatment better from a placebo?" no discernible effect on anxiety unless a in fact, they were told in great detail about That kind of thinking, still hard for person knows he is taking it. And, in- the placebos they received and that they most doctors to accept, was heretical in creasingly, studies like those have been were often as effective as real medicine. 1990, when Kaptchuk arrived at Har- carried out with the help of imaging The pills brought them relief. vard. "People kept saying, 'Oh, this is just techniques—such as PET scans and func- For many people in the field, results the placebo effect.' You would hear that tional M.R.I.s—that can track brain like those achieved in the morphine and every day," Kaptchuk said. He had spent changes as they happen. These advances I.B.S. studies, while preliminary and in years studying Chinese medicine (and in brain imaging, along with an increased need of confirmation, hint at something medical history), and this made no sense understanding of neurochemicals, have far more significant than the effect of a to him. "I thought, Ted, step back a transformed a vague and mysterious no- placebo or problems with a particular minute. This wasn't just something that tion into a tangible effect that scientists drug. They suggest that the "magic bullet" was a negative. It was something that consider worthy of investigation. approach to health care—ample, effective needed to be understood." "What's exciting here is that, if we are solutions to single problems, like a step Slowly, over the past decade, re- to talk about using placebos in a clinical infection or polio—can no longer remain searchers have begun to tease out the setting, they would have to have a mea our principal approach to treating disease. strands of the placebo response. The surable effect and a biology we under- There has always been a distinction findings, while difficult to translate into stand," Wayne Jonas told me. Jonas is an between disease and illness. Disease is a medicine, have been compelling. In most interesting hybrid in a world often biological condition that we have histor- cases, the larger the pill, the stronger the sharply divided between conventional ically treated with drugs, surgery, and placebo effect. Two pills are better than and alternative therapies. In the early other technological solutions. Illness, on one, and brand-name pills dump gener nineties, he served as the director of the the other hand, defines the context of a ics. Capsules are generally more effective Medical Research Fellowship Program medical encounter, including the rela- than pills, and injections produce a more at the Walter Reed Army Institute of tionship between doctor and patient. pronounced effect than either. There is Research, in Washington, D.C. He went Like Kaptehuk, Jonas believes that pla- even evidence to suggest that the color of on to run the Office of Alternative Med- cebo research demonstrates that it is es- medicine influences the way one re- icine at the National Institutes of Health, sential to consider both the science and sponds to it colored pills are more likely from 1995 to 1999. Today, Jonas is the the art of medicine—to think about din to relieve pain than white pills-, blue pills president of the Samueli Institute, a eases as illnesses, and not to rely solely on help people sleep better than red pills; Washington research group devoted to short-term, high-tech solutions. Scien- and green capsules are the best bet when shifting the focus of health care from tists hope that, even if it proves impossi- it comes to anxiety medication. treatment to prevention. ble to replace drugs with placebos, re- Conditioning and expectations mat- 'he morphine studies bring us a long search into the way they affect us will ter, and so does learned behavior. In the way," he said. So did a recent investiga accomplish nothing less than a transfor- eighties, Levine and Gordon divided a don by Kaptchuk, in which participants mation of American medicine. 'There are group of postoperative patients into three sections: those in the first section re- ceived morphine secretly, those in the second were told they would receive morphine (and did), and those in the third were given a placebo that was de scribed as a powerful pain reliever. The results were startling. Patients who were told that they would receive a painkiller, whether they actually received it or not, had the same experience in the trial as those who secretly received between six and eight milligrams of morphine—a significant amount. The covert dose had to be increased to twelve milligrams to surpass the effect of the placebo. Over the past two decades, the Italian neuro- scientist Fabrizio Benedetti (who studied with Gordon and Levine), and Luana Colloca, a colleague of Benedetti's, who Anovit/n4.4.1 is now based in the United States, at the National Institutes of Health, have expanded on these studies. They have Bore me to sleep, Daddy." EFTA_R1_02046879 EFTA02695682  placebos as drugs. But I have no idea what that means in practical terms. Flow would it work?" Tantalizing hints and possible effects are not data, and Temple says there are no data that would suggest that place bos are drugs. There are several studies, though, that illustrate the basis for his skepticism. A placebo effect is commonly ob- served during trials of blood-pressure medications. To qualify for such studies, subjects are supposed to have blood pres- sure that exceeds a hundred and forty over ninety in at least one of the two measurements. "As soon as somebody enters those studies, his or her blood pressure falls an average of five or six mil- limetres of mercury," Temple said. 'That We's the chiefwatchdog, who watches over all the other is significant, but it is not a placebo re watchdogs—but this must be his night of" sponse, and it is not a response to being in the study. It is often the result of doe • • tors' inflating readings—of rounding up." If a person's blood pressure is a hundred and thirty-eight over eighty-eight, for ex- no magic bullets for most of the problems term 'placebo,' which does nobody any ample, investigators will often include that ail us today," Jonas said. "Diabetes, good," Robert Temple told me, echoing him. "When you use an automatic blood- immune-system disorders, chronic pain, a complaint made by virtually every- pressure cuff to establish a baseline for cancer. Our illnesses are complex, and we one who deals with the subject. Temple, these kinds of studies, the entire placebo need to approach them in more compre- who has for many years run the F.D.A.'s effect vanishes," Temple said. hensive ways. We try to identify drugs drug-evaluation department, is an owlish When a drug (or a placebo) is under that will eliminate disease. Yet the way man with a short, thick mustache and cir study, subjects are usually divided into two we go about delivering those agents—the cular glasses. His office is so filled with groups. Neither group knows exactly what interaction between doctor and patient, towering stacks of files that, after you it is getting (nor do the doctors), but one for example—often has a bigger impact enter, it takes a moment to find him. "Just group generally receives the drug and the than the agent we focus on. More than because something is called a 'placebo other a placebo. "There is a better way," the drug and more than the surgery. And group,' " he said, "everyone assumes that Temple said. "If you want to see if there is that has been collectively called the phr what happens in that group is a result of a placebo effect, use three arms in a drug cebo effect." the placebo effect. And that is absolutely trial, not two. Tell them, 'Some of you will not true." be getting a drug, some will get a tablet T he headquarters of the Food and Drug Administration, situated on a campus called White Oak, on the far Temple, who has worked at the F.D.A. for four decades, rarely makes a decision without angering somebody. He that looks like a drug but is nothing but a sugar pill, and some of you will get cloth ing at all: edge of Silver Spring, Maryland, seems has been regarded as a meddlesome reac- "It seems to me," he went on, "that if as close to the rest of the federal medi- tionary by H.I.V. activists and others there is any substantial placebo effect, cal establishment as it is to Pluto. 'There who insist that drugs be released more there ought to be a difference between the is no Metro to White Oak, and it takes rapidly. The more conservative medical group that knows it's getting nothing and half an hour to drive from the sprawling establishment frequently accuses the the group that doesn't know it's getting campus to the National Institutes of agency of endorsing the wishful thinking nothing. If there is no difference, then Health, in Bethesda. The F.D.A.'s of drug manufacturers. And to the large what are we talking about? Because it's physical isolation belies its position as and growing community that supports not a placebo effect." the nation's principal regulator of con- alternative approaches to medicine Tem- It turns out that there have been many sumer products. No drug is sold with- ple is Dr. No. trials of the type Temple mentioned. In out the agency's approval. There will be Temple said that he understands why 2001, the Danish epidemiologist As- no prescriptions for any placebo, either, placebos attract people who become frus- bjern Hr6bjartsson, of Copenhagen's unless clinical trials have demonstrated trated when science fails to provide Nordic Cochrane Center, along with his its effectiveness to the satisfaction of definitive answers. "The persistence of colleague Peter Gotzsche, published a the F.D.A. what people believe will save their lives as systematic review of a hundred and four- "One of the absolutely fundamental opposed to the evidence is staggering," he teen clinical trials that compared patients problems that we have is the use of the said. "So people are talking about using who received a placebo with subjects who 54 11-IE MEV 'OMER. DECEMBER IL 201 EFTA_R1_02046880 EFTA02695683 were told that they would receive no medical care. Effective long-term thera- pharmacological way of handling illness— medicine at all. The researchers at- pies have proved elusive. In Kaptchuk's that there is a pill for every disease. tempted to assess the combined impact study, eighty patients were randomly di- "The entire idea of a placebo is very of many different kinds of trials using vided into two groups. Patients in the first 'soapy:" Hrobjartsson continued. "It slips meta-analysis, a statistical technique for group received a placebo pill twice a day, away whenever you try to find a border." extracting information from studies that those in the second received nothing. Be- That has always been true. After all, for are not statistically significant by them- fore the study began, both groups were many people a placebo is just a sugar pill. selves. Their article, "Is the Placebo Pow- told that placebos were "inert or inactive For others, the definition includes the en- erless? An Analysis of Clinical Trials pills, like sugar pills, without any malica- tire ritual of treatment, the complete inter- Comparing Placebo with No Treat - tion in them." They were also informed action between doctor and patient. In- ment," published in The New England that placebos have been shown in "rigor- creased attention has mostly raised new Journal ofMeditine, was a long-overdue ous clinical testing to produce significant questions: What are the physical and per response to Beecher's 1955 paper. mind-body self-healing processes." Pa- chological mechanisms that produce pla- In almost every case, the researchers re- tients who received the openly distributed cebo theses? What are the conditions they ported, there was essentially no difference placebo scored flu better on standard as- most easily affect? And can we actually between the placebo group and the openly sessments of their condition than those identify people who respond to placebos? untreated group. There were particular ex- who received nothing. There were also Scientists now haw bits of answers to some ceptions in studies of pain, where there statistically significant differences in the of those questions, but to reach their goal, was a slight but measurable placebo effect. severity of symptoms. and introduce placebos into clinical prac- Since we are physiologically capable of Although a group of eighty patients is tice, they will need to answer all of them. manufacturing our own painkillers—en- too small to draw definitive conclusions, dorphins—the result may not have been surprising. Expectations and suggestion dearly influence behavior, and when we honesty seemed to work. "Asbjom's stuff is a constant intellectual challenge," Kapt- thuk wrote in an e-mail. "His meta-anal- T ed Kaptchuk gets a great deal of pleasure from focussing on what other people reject. Indifference seems to expect to receive medicine our bodies yses are tops. Great methods, very carefuL motivate him. "I was raised in a crazy often begin to prepare for it. (As the eve Clear." Yet Kaptchuk also pointed out home, and it prepared me to accept any lutionary biologist Robert Trivers recently that placebos are not the only interven- proposition," he said. That, he once told pointed out, in 'The Folly of Fools," his tions that can cause complicated reac- me. is why he was so active in the sixties: book about the historical necessity of de- tions. Drugs do, too. °plods, for exam- "It was a time when the underpinnings of ceit, what the brain expects to happen in ple, increase pain in about ten per cent of the universe were questioned." Both of the near future affects its physiological those who take them. Antibiotics don't al- ICaptchules parents, who were Poles, sot state. Trivers's theory would explain a fact ways work, and neither does cortisone, a vived the Holocaust. "That redly defines that has often baffled scientists: the pla- powerful steroid used each year by mil- a lot of what I do. My father was a Red, cebo effect doesn't appear to work with lions of people. Meta-analyses are useful so I have a tendency to get pleasure from Alzheimer's patients. Trivers suggests that to help understand large amounts of data subversiveness." this is because most people who have Al- from different trials. But statistical results A particularly radical son of the six- zheimer's disease are unable to anticipate that combine information from a ties, Kaptchuk was one of the the future and are therefore unable to prc- variety of medical centers, with founders of the Columbia Uni- pare for it.) different kinds of patients, often versity chapter of Students for The Danish researchers repeated the in different countries, adminis- a Democratic Society, in 1%5, study in 2004, and again last year, incor- tered under different conditions, but the organization was soon porating new data each time. The re- cannot be uniform and therefore dominated by a faction that be- sults and their conclusions remained cannot be conclusive. came the Weather Under - the same. "We found little evidence in Hrobjartsson and Kaptchuk ground. That was too radical general that placebos had powerful clin- are united on at least one front. even for Kaptchuk. He fled to ical effects," linthjartsson wrote. "Out- Like Wayne Jonas, they agree the West Coast. "I was hanging side the setting of clinical trials, there is that the medical system needs to out with the San Francisco Red no justification for the use of placebos." change. "You have to put this into Guards and reading Mao, trying Kaptchuk has great respect for Hro- the context of the society in which to get away from U.S. imperial- bjartsson, yet he is wary of relying on you live," Hn5bjartsson told me. "Because ism," he said. "I was militant and crazy. meta-analyses, and he believes that an I think this may be as much a matter of But at some point I said, Ted, this is not honest interaction between a doctor and philosophy as of science. There is an anti- being human." a patient can significantly alter the out- technological, anti-science feeling in the Kaptchuk decided to pursue studies in come of treatment. That was the point of West. We constantly see frustration with Chinese philosophy and medicine at the his study of irritable-bowel syndrome, in the limits of medicine. The placebo can be source. Beijing had yet to open its bop which some subjects were told that they seen in some sense as a logical avenue for ders to Americans, but Kaptchuk hoped would not be treated. I.B.S., a chronic those frustrations. Everyone wants a sim- that his revolutionary bona fides would gastrointestinal disorder, is one of the ple, pain-free solution. But I wonder if that prompt the leadership to make an excep- most common reasons that people seek approach isn't just the mirror image of the tion. "My request to study there was de- THE NEV IORKER. DECEMBER e. 201 as EFTA_R1_02046881 EFTA02695684 livered to the government by members of though he has received millions of dol- doctor really supposed to say, Gee, the the Black Panther Party," he told me. lars in funding for his projects from the patient is feeling good but I better ig- Even that didn't work. The Chinese de- National Institutes of Health. The goal nore that and go by the numbers?" nied the request, and Kaptchuk spent is to understand placebos so that they It was late in the afternoon, and we much of the next decade studying in may be used intelligently," he said one were sitting in Kaptchuk's garden in Macau. day. "But this is the area where I veer Cambridge. He looked at me and threw Today, it is hard to imagine Ted from some of my colleagues. Because his hands into the air. "Is my approach Kaptchuk as a radical, let alone a fugitive. what do I really want? Anything that just hocus-pocus?" he said softly. "Isn't He is an observant Jew who wears a yat- gets people away from the conveyor belts that what you are really asking? You want mulke on top of a shaggy bowl haircut that move from the pharmaceutical to know the relationship between ratio- that looks as if he'd copied the Beatles, houses to doctors and on to patients is nality and feeling and between science, circa 1964, then let it grow. As a devotee worth considering. Anything. We need critical thinking, and the art of medicine. of Eastern thought, he bars shoes from to stop pretending it's all about molecu- And that boils down to one question: Do his house and speaks in a hushed, mea- lar biology. Serious illnesses are affected you think this entire field is based on a sured voice. David Carradine would have by aesthetics, by art, and by the moral foundation of magical thinking, or do played him beautifully. questions that are negotiated between you not?" Kaptchuk is the first prominent pro- practitioners and patients. Chiropractors fessor at Harvard Medical School since never say that your pain is all in your Three years ago, a week before Erik Erikson with neither a medical de- head. But orthopedists do it all the time. .L Thanksgiving, while I was sitting in gree nor a doctorate, and it would be easy What a fucking way to try and help my office, my chest began to throb. It to dismiss him as a signature representa- somebody heal. Do you know how evil was a diffuse pain, but pain nonethelen. tive of the unsubstantiated-alternative- that is?" I am a middle-aged man with the usual health-care movement. But he has pub- That kind of deeply held conviction amount of stress (too much) and I han- lished scores of books, articles in highly touches on the fundamental questions dle it in the usual way (denial). My cho regarded peer-reviewed journals, letters, that challenge American medicine. lesterol and blood pressure are normal, and review notes—on subjects ranging Kaptchuk wants to broaden the defi- and I exercise regularly and try to eat sett from placebo research to exorcism, from nition of healing, which is exactly what sibly. Still, I have read many obituaries of cancer treatment to shaman rituals among enrages many scientists. In one recent "healthy" men my age who ignored chest Navajo Indians. He has just finished a study of a major asthma drug, he and his pain. So, somewhat sheepishly, I called study designed to answer a central quell- colleagues reported that, although place- my doctor and explained the situation, tion in placebo research: Do the genes of bos had no impact on the chemical and he told me to come right over. people who respond to placebos differ in markers that indicate whether a patient He conducted a thorough examina- significant ways from those of people is responding to therapy, patients none- tion, and then we talked. He told me I who don't? (The data, compelling but so theless reported feeling better. Kaptchuk was fine, that Thanksgiving is often a far preliminary, suggest that the answer concluded that objective data should not tense time, and that I should relax. My is yes.) be the only criterion for doctors to con- pain suddenly disappeared. I have writ- "Ted Kaptchuk is the most knowl- sidct. "Even though objective physiolog- ten frequently of my belief that magic edgeable person in the world on all mats ical measures are important," he wrote in is for fairy talcs and science is for hu- ters placebo," Franklin Miller told me. the study, published earlier this year in mans. But something about that process Miller is a senior faculty member in the The New EnglandJournal ofMedicine, soothed me. Of course, it was a relief to Department of Bioethics at the National "other outco