The Medical Challenge — A Post by John S. Haller Jr.
The following post is by John S. Haller Jr., author of Shadow Medicine: The Placebo in Conventional and Alternative Therapies:
“The placebo has undermined the positivist model of biomedicine by interjecting subjectivity, uncertainty, and ambiguity into the clinical encounter. It suggests that a specific disease or illness does not exist apart from the manner in which the society conceptualizes it and addresses it.”—John S. Haller Jr.
Conventional medicine is founded on the belief that the body is the outcome of material forces. Given this assumption, it looks to physiological, pathological, biochemical, and molecular processes derived from physical matter to diagnose and treat disease. Its basic tool is the randomized clinical trial, guided by the fact that its active pharmaceutical substances “work” (even when the patient is unaware of their administration) and that their effects can be demonstrated, measured, and replicated. As authority figures, conventional physicians not only project a certain level of scientific legitimacy but purport to have legal authority, political privilege, and cultural acceptance—entitlements that also come with obligations that include standardized training, accreditation, licensing, and regulation.
While the randomized clinical trial provides the most credible information for justifying a specific treatment, its ultimate value remains uncertain because much of what happens in a trial fails to capture the myriad of independent and/or related variables that affect the physician/patient encounter. For all its hype, the randomized clinical trial remains an imperfect tool. Although it informs individual clinical expertise, it does not (and should not) replace it. Conventional medicine has overestimated the value of its clinical trial and more creative methods are needed that compare “whole treatments” rather than just the normative components which biomedicine is most acquainted.
In contrast to conventional medicine, complementary and alternative medicine (CAM) defines health in psychological and spiritual terms and emphasizes patient individualization and self-healing. It is founded on a philosophy of organism known as “vitalism” which explains life not by the laws of physics and chemistry but by a principle, force, or spirit-like power that comes from beyond the material world to animate organic matter. Consisting of a mixture of religion, mysticism, cosmic energy, disbelief in Western reductionism, and an increased fascination with Eastern philosophies, CAM encourages a more metaphysical encounter with the world, one that questions the basic assumptions about the nature of reality. In this new setting the patient’s experience becomes intensely personal and compares strikingly to certain types of spiritual awakening. In its intuitive approach to healing, the goal of the healer is to assist the individual in finding harmony with nature.
CAM practitioners are a diverse group, only some of whom come with special access to rational scientific knowledge, training, and competence in special skill sets. In general, the unconventional healer is someone who relies on intuitive insight and encourages a more egalitarian relationship with the patient—replacing reductionist thinking with notions of spirituality, meditation, insight, attitude, and behavioral modification.
With eighty percent of the world’s population, including half of the U.S., using some form of CAM, the scientific community can no longer ignore it as simply a fringe therapy used by uninformed consumers. Nevertheless, unlike biomedicine which justifies its existence through clinical trials, most CAM therapies have yet to prove their efficacy, relying instead on anecdotal information and a static set of principles and practices that appear to “work.” To date, only a few therapies have provided a scientific explanation of their efficacy that fit within the context of normative science.
Enter the placebo which for centuries has found a home in the physician’s handbag, albeit as a nuisance or dark secret. For too long, biomedicine had devalued it with such words as inert, inactive, nuisance, dummy, and sham. Defined as a method or medicine used by physicians when nothing else seems to work, it was intended to satisfy patients’ imaginations, beliefs, and expectations while nature took its course. This led physicians to relegate the placebo to an indefinable, unintended, and nonspecific category folded in with the body’s self-healing capacity, spontaneous remission, natural history, and other indeterminate elements. Marginalized in the pharmacologically centered world of drug experimentation, it was reserved for status as a “control” in evaluating an agent or procedure in a clinical trial.
Few anticipated the prominence the placebo would garner in mid-twentieth century when Harvard anesthesiologist Henry K. Beecher announced in “The Powerful Placebo” (JAMA, 1955) that in clinical trials the effects of the placebo often exceeded the effects of a pharmaceutical drug. Beecher brought the placebo out from its marginal place to center stage. His thesis hinted at the medicalization of phenomena that had thrived over the generations under umbrella terms such as suggestion, positive thinking, and affirmation. Essentially, Beecher’s findings challenged the therapeutic efficacy and limits of the randomized clinical trial which experts had identified as the gold standard within conventional medicine’s evidence-based pyramid.
Due to the fact that the placebo effect is different from one individual to another, from one culture or subgroup to another, and is rarely equivalent to no intervention at all, it remains one of the contradictions in modern medicine’s conceptual structure. There is sufficient evidence, however, to assert that the placebo is more than a psychological prop. It undermines the misplaced hubris found in biomedical reductionism in that the objective reality used to explain the disease or illness hides an unmapped world of the patient’s subjective self. Under the right circumstances any number of factors can elicit a positive placebo response. The placebo can even have a direct modulating effect on the treatment itself and arguably be regarded as a second therapy rather than as the absence of a therapy.
The placebo has undermined the positivist model of biomedicine by interjecting subjectivity, uncertainty, and ambiguity into the clinical encounter. It suggests that a specific disease or illness does not exist apart from the manner in which the society conceptualizes it and addresses it. In other words, disease and illness exist in and through the lens of a culture and its particular values, limits, and contexts.
In the interest of both reductionist science and CAM, the next decade must bring together the polar entities of objectivity and subjectivity in a viable, observable, and replicable evidence-based system that will separate those belief systems that remain wedded to a priori laws and principles from those that can stand with biomedicine as partners in the nation’s healthcare system. The clinical encounter represents the nexus of biology, medicine, and meaning. Integral to this encounter should be the placebo in all its current and future guises.
Making this argument for the integration of subjectivity and objectivity into the evidence-based pyramid does not negate past findings; nor does it rule out the role and purpose of the randomized clinical trial in the absence of a viable alternative. Until now, reductionist medicine has remained the most trustworthy form of therapy due to its willingness to be subjected to the constant challenge of verifiability and replicability—an intense process of error detection in pursuit of some unifying (even if temporary) “truth” or “meaning.” Still, science remains conceptually unsettled, and always will be.
One learns to appreciate that belief systems which seem illogical and irreconcilable with normative science may still work. The question at hand is not only whether conventional and unconventional therapies can stand on their own self-authenticating authority, but whether it is possible to modify the context of these two opposing camps into something both can benefit from sharing. To date, there is no hard-wired connection, but the bridge between them is nowhere as long, nor is the chasm beneath them as deep as it once appeared.
