Placebo effect

Personal injury attorneys know a lot of medicine.  They may not know it well.  They may not understand what they know.  But they grasp it well enough to persuade a jury that they understand medicine as well, if not better, than the physician who is testifying.

Those of us who have spent our careers as defense attorneys -- persuading juries that injured plaintiffs were not really injured, or at least not injured as badly as they say they are -- find our quasi-medical erudition flavored with a healthy dose of cynicism.

"Of course you are suffering from "whiplash"," we sneer, putting sarcastic air quotes around "whiplash.".  "Of course your lung cancer was caused by that rear end accident six years ago."

One aspect of medicine with which we are well familiar is the "placebo effect" -- the known fact that many patients who complain of pain do in fact feel much better if provided totally worthless treatment.  For example, if a physician tells the patient that he's giving him or her a pain reliever, but actually provides sugar pills, the patient will often actually feel much better.  This suggests to a newbie defense attorney that the injury was fake to begin with.  But doctors he trusts will assure him that even a real injury will respond to the patient's belief that he is being given drugs or other treatment that will relieve his pain.

An article by Gary Greenberg in the New York Times Magazine examines recent research into the placebo effect.  As the article notes:

Give people a sugar pill, they have shown, and those patients — especially if they have one of the chronic, stress-related conditions that register the strongest placebo effects and if the treatment is delivered by someone in whom they have confidence — will improve. Tell someone a normal milkshake is a diet beverage, and his gut will respond as if the drink were low fat. Take athletes to the top of the Alps, put them on exercise machines and hook them to an oxygen tank, and they will perform better than when they are breathing room air — even if room air is all that’s in the tank. Wake a patient from surgery and tell him you’ve done an arthroscopic repair, and his knee gets better even if all you did was knock him out and put a couple of incisions in his skin.

The article examines two possible bases for the placebo effect:  One, the more classically "medical," is that certain brain chemicals -- those associated with stress, reward, and good feeling -- are produced in some, but not all, patients in reaction to the interaction that the patient has with a doctor whom he trusts.

This makes sense to me.  If stress can give you a headache or an upset stomach, a caring relationship with a doctor or an acupuncturist or a naturopath could well make your backache feel better.

The second approach, insofar as I understand it, may be completely compatible with the first.  Maybe only the emphasis is different.  Its proponents feel that the placebo effect results almost entirely from the caring interaction between doctor and patient.  These researchers are more interested in the caring relationship than in any chemical or "molecular" basis for the placebo effect.  Their primary proponent, Ted Kaptchuk, has done

a comparative study of conventional medicine, acupuncture and Navajo “chantway rituals,” in which healers lead storytelling ceremonies for the sick. He argued that all three approaches unfold in a space set aside for the purpose and proceed as if according to a script, with prescribed roles for every participant. Each modality, in other words, is its own kind of ritual, and Kaptchuk suggested that the ritual itself is part of what makes the procedure effective, as if the combined experiences of the healer and the patient, reinforced by the special-but-familiar surroundings, evoke a healing response that operates independently of the treatment’s specifics.

"Whoa," I might have exclaimed if I'd taken this fellow's deposition.  "Voodoo medicine."

I'm less skeptical now, partly because the two approaches tend to examine the same phenomenon, merely from different directions.  The more intense the providing of medical care, or the Navajo chanting, or the administering of acupuncture by an empathetic practitioner, the more likely the production of the appropriate brain chemicals under the purely medical model.

Many people, both doctors and laymen, worry that medicine has become too cold and impersonal.  An annual medical exam too often feels like a quick check to see if any expensive drugs or procedures are justified.  If new developments in the understanding of placebo medicine lead to a greater realization that a warm and empathetic relationship between the physician and the patient is therapeutic in itself -- not just as a means to reach a proper diagnosis -- we may be approaching a more effective and satisfying form of medicine.

My skepticism remains to some degree, but is tending to fade away.  As Shakespeare had Hamlet declaim some five centuries ago:

There are more things in heaven and earth, Horatio,
Than are dreamt of in your philosophy.

And that may go for medicine as well.