Miracles do not happen in contradiction to nature, but only in contradiction to what is known to us of nature.
You do not have to know what the sun is made of to see by its light. You do not have to understand electricity to flick on a switch, nor understand brain chemistry to think. And you do not have to investigate the etiology of any disease or any given treatment in order to experience the placebo effect.
What exactly is a placebo effect? In the first chapter I defined it as an effect with no external cause. This sounds like a paradox; the absence of cause would logically preclude the possibility of effect. But what seems to be paradoxical may simply indicate that we have stumbled across the edge of our ignorance: Paradox marks a limitation of knowledge, not an impossibility in reality. Much of modern physics is defined by apparent paradox. Physicists investigate whether light is composed of waves or particles, that is, of energy or matter, and the answer they receive is, paradoxically, both. The paradox of the placebo effect is far easier to resolve: It is the external effect of an internal cause. That is, it is a physical demonstration of a state of mind.
Doctors have attempted to define the placebo effect, but very few are as willing as Dr. Douglas Black, the aforementioned president of Britain's College of Physicians, to pull the rug out from under the whole medical profession. Dr. Black said, "New drugs create new hopes," and he advised an audience of doctors that "one should treat as many patients as possible with a new drug while it still has the power to heal." (Italics mine.) The implications should have boggled the minds of the audience: Why would a patient's hope increase the power of a pharmacological substance, and what could cause such a substance to lose its power? But physicians' responses to statements such as Dr. Black's reminds me of the humorous TV commercial in which two men lost in the desert stumble right past the Land Rover that could carry them to safety, because they think it is a mirage.
The word "placebo" can be traced back to the fourteenth century when it was used in vespers chanted for the dead, and derives from the Latin translation of Psalm 116.9: "Placebo Domino in regione vivorum" [I will please the Lord in the land of the living]. Placebo came to mean "I shall please"; but today its usual connotation is to please by deception. Hooper's Medical Dictionary of 1811 defined placebo as "an epithet given to any medicine adopted to please rather than to benefit the patient." A hundred and eighty-two years later, in 1993, Merriam-Webster's Collegiate Dictionary, 10th Edition, defines it almost the same way: "a medication prescribed more for the mental relief of the patient than for its actual effect on a disorder." A 1973 edition of The Dictionary of Behavioral Science (DBS) begins with a more promising definition: "a substance with no medicinal properties which causes a patient to improve because of his belief in its efficacy." But the DBS goes on to negate the idea that real improvement occurs: "It reinforces the patient's expectations though it does not really act on the individual's condition." (Italics mine.)
The usual definitions of the placebo effect imply fakery and reinforce commonplace assumptions like these: (1) If a patient responds to a placebo, his symptom was either feigned or imaginary. (2) The only symptoms placebos can act upon are anxiety or pain. (3) Placebos, whether they help or not, at least are harmless. (4) Only neurotic personality types respond to placebos.
Psychologists and psychiatrists are the two categories of health professionals that show the most interest in the placebo effect, and each school of psychotherapy contributes its own spin.
Behavioral psychology finds the placebo effect akin to the Pavlovian response: Just as a dog salivates when a bell associated with food rings, so a patient enters a cure mode when something associated with a cure is present. The conditioning agent need not be medicine: It could be the setting--a doctor's office or a hospital--where one expects to get help. It could be merely attention from a surrogate of the person who in the patient's childhood "kissed it and made it better"--a role most often played by a doctor. Behavioral psychologists have indeed come close to the truth of self-healing. They recognize the power of association and expectation to function as placebos, yet they refrain from articulating the conclusion that the psyche governs healing.
Among psychotherapists in general there is much grappling with the definition. A placebo has been called all of the following:
Taken together these definitions broaden the concept of placebo to include everything--real medicines and sugar pills, voodoo dolls and physician's personalities, surgery and a good day at work, a doctor's office and the shrine at Lourdes. And a placebo effect would include not only good effects but also bad effects.
This is exactly right. In other words, the number of placebos is infinite. A placebo may be anything--intended and not intended, an active and an inert drug, the disposition of the doctor and the faith of the patient. Any of these may trigger a cure or may intensify an illness.
Now we are in territory where science as currently practiced cannot go, for science seeks to pinpoint the exact cause of any given effect: It simply can't handle a phenomenon that can be caused by anything and that may be equally not caused by the same "anything." We are in metaphysical territory, the territory of the mind.
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