An Interview with John Haller, author of Shadow Medicine

“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.”—John S. Haller Jr.

John Haller, Shadow MedicineThe following is an interview with John S. Haller Jr, author of Shadow Medicine: The Placebo in Conventional and Alternative Therapies. For more on the book, read John Haller’s essay The Medical Challenge:

Q: In Shadow Medicine, you use the term conventional medicine. What do you mean by that?

John Haller Jr.: Conventional (or reductionist) medicine identifies statistical baselines against which to measure its therapies, looking to physiological, pathological, biochemical, and molecular processes derived from physical matter and to treatment based on the calculus of probabilities. That is to say, conventional medicine draws its authority from the clinical trials and laws embedded in the natural sciences. At its best, conventional medicine encourages a healthy skepticism and urges various forms of sampling, followed by repeated experimentation to reaffirm a hypothesis. Its identity is thus based on the unambiguous application of normative science whose laws interpret the body as a materialistic system that can be reduced and analyzed according to its component parts.

Q: You seem to suggest, however, that conventional medicine has limits? How so?

JH: While conventional medicine continues to provide the most credible information for justifying a clinical judgment, its ultimate value remains uncertain because much of what happens in a clinical trial fails to capture the myriad of variables that affect the physician/patient encounter. For this and other reasons, the clinical trial remains an imperfect tool.

Calibrating the outcome of a medical procedure or the efficacy of a pharmacologic treatment defies certitude insofar as the organic side of medicine tends to be infused with psychotherapeutic interventions—some intended and, others, hidden. This suggests that conventional medicine has overestimated the value of the clinical trial in resolving the challenges presented in medicine and that more creative efforts are needed that compare “whole treatments.”

Q: How does conventional medicine contrast from complementary and alternative medicine?

JH: Today’s complementary and alternative healers focus their attention on forces or energies that, although undetectable by the tools of science, are thought to be real. Such phrases as “paradigm change,” “probability waves,” “string theory,” “chaos theory,” “new physics,” “ectoplasm,” “chakras,” and “spirit-release therapy” are used to anoint beliefs wholly distinct from empirically-based laboratory science. Challenging the discrete boundaries between objectivity and subjectivity by including consciousness in the reframing of reality, today’s unconventional healers insist that “life forces” can be transmitted or channeled into the patient to mediate physical, mental, or emotional needs. This secularized notion of body, mind, and spirit forms the basis of homeopathy, psychic healing, crystal healing, reiki, light therapy, acupuncture, qigong, aromatherapy, distant healing, transcendental meditation, therapeutic touch, and other paranormal healing systems.

Q: I notice that you use the term post-modernism in a medical context. How is it that you feel justified in placing medicine in that context?

JH: Historian John Lukacs, in At the End of an Age (2002) concluded that the authority given to science had been inflated to the degree that it disconnected the objectivity of the researcher from any fallibility as a human being. Medicine’s golden age came to an end in the late 1960s and early 1970s when its authority was challenged by an amalgam of diverse cultural trends, heady intellectual discourse, consumerism, a service and information economy, a culturally based to approach to knowledge, and a shift in autonomy from doctors to patients. For the postmodernist, what existed as reality was relative to the observer and molded by culture and social influence. Applied to medicine, postmodernism infers that the “truth” of an illness is no longer in the physician’s objectivist and biomedical account, but in the patient’s narrative, which is not only distinctive, but often confusing, if not self-contradictory.

Q: Where does the placebo fit into the world of conventional and unconventional therapies? How would you describe the placebo to someone?

JH: The placebo is the ghost that haunts the world of the physician/healer. Not only are its effects different from one individual to another and from one culture (and even subgroup) to another, it is also 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 biomedicine 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.

Q: Explain why you have taken such an interest in the placebo effect?

JH: For centuries the placebo found a role in the physician’s handbag as both a nuisance and a dark secret. In 1949, the editors of the British Medical Journal estimated that 10 percent of the 188 million prescriptions dispensed in Great Britain were placebos. In British hospitals, doctors maintained stocks of sugar pills and saline injections for patients who were unresponsive to pharmacologic regimens. This practice of using placebos was justified not only on economic grounds, but because in some cases they had a more powerful effect than known pharmaceutical agents.

Formulated in the shadow of evidence-based medicine where it was employed to eliminate bias, the placebo was overlooked as an active intervention strategy. For too long, conventional medicine dismissed it with such words as inert, inactive, nuisance, dummy, and sham. Indeed, both conventional and unconventional medicine chose to ignore placebo intervention as a distinct entity, believing instead that their individual therapies were self-authenticating and equated fully to the effects produced on the body. By ignoring the placebo as a distinct entity, they inferred that their clinical outcomes were effective regardless of any supportive nonspecific effects.

Q: What happened to change this behavior?

JH: Few anticipated the prominence the placebo would garner in the 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 suggested that placebo treatments helped approximately one-third of patients with their diseases and illnesses. His thesis hinted at the medicalization of phenomena that had thrived over the generations under terms such as suggestion, positive thinking, and affirmation. Essentially, Beecher’s findings challenged the therapeutic efficacy and limits of the double-blinded, placebo-controlled clinical trial which experts identified as the gold standard within conventional medicine’s evidence-based pyramid.

Q: Does the placebo have a similar effect on complementary and alternative medicine?

JH: Definitely yes. The findings question whether most if not all complementary and alternative therapies fall under the umbrella of the placebo effect, suggesting that their strength lay rather in symptom management and in personalized strategies for health promotion. Essentially, unconventional medicine chooses to dismiss the placebo as a tool intended to marginalize its various therapies.

Q: So, what do you see in terms of medicine’s future?

JH: As we look to the future, it seems especially important to examine more closely the variables that are lodged deeply in our respective cultures. In the interest of both conventional and unconventional medicine, the next decade must bring together the polar entities of objectivity and subjectivity in a viable, observable, and replicable system that will separate those belief systems that remain wedded to a priori laws and principles from those that can stand as viable 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 (i.e., what we call today integrative medicine) into the evidence-based pyramid does not necessarily negate past findings; nor does it force the acceptance of delusional theories like homeopathy’s water-memory or rule out the role and purpose of the clinical trial in the absence of a viable alternative. Until now, conventional 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.

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.

1 Response

  1. While it is certainly true that placebo is an important effect on treatment outcome (Maharishi Mahesh Yogi once famously remarked “This is how God, whispering to Himself, creates the universe, and you dismiss it as ‘placebo’!”), not all ‘alternative” practices, including purely mental ones, can be described purely in terms of placebo effect.

    And no all alternate practices are the same.

    In the scientific statement on Alternate treatments for hypertension, the American Heart Association found that every meditation and relaxation practice had no significant or consistent effect except Transcendental Meditation.

    http://hyper.ahajournals.org/content/early/2013/04/22/HYP.0b013e318293645f.full.pdf

    The AHA called for head-to-head studies of the various meditation practices and their effect on hypertension, and of course, such studies are needed when establishing the efficacy of any alternate practice.

    Even the best protocols used by most researchers (active control groups) are not sufficient to truly study alternate therapies properly. It is well known that even when experimenter bias is controlled for when evaluating data by using blinded experimenters, the bias of the researcher can influence how other people involved in conducting studies behave, which can also influence the outcome. For example, the people conducting classes in health education may be aware that they are involved in the control group, and that no-one expects their group to do well on the test. This attitude might be transmitted to their students, leading to lower participation and lower outcomes.

    The best way to control for experimenter bias is not by having fully disinterested researchers conduct the research but by having teams of researchers with competing bias, jointly design and conduct the researcher.

    The following study included at least one proponent of each practice studied: Transcendental Meditation, mindfulness and Relaxation Response (euphemistically called “low mindfulness relaxation” in the final paper to allow for political correctness of a Harvard professor publishing research that called into question another Harvard professor’s work). Each meditation teacher was required to meet the standards of professionalism of the TM teachers; professional attire & grooming, high familiarity with course materials [i.e., memorized], presentations made using slick graphics derived from actual research on the practice the they were teaching, a belief that the practice actually was of value, etc.

    Subjects were randomly assigned to a practice, given an intro lecture by their new teacher, and then surveyed to determine expectations. No significant difference in expectations between groups was found.

    Data acquisition was performed by blinded graduate students from Harvard University.

    http://www.ncbi.nlm.nih.gov/pubmed/2693686

    This study was published nearly 25 years ago, and no recent study on meditation (or any other alternate therapy0 even comes close to the robustness of protocol design and implementation. Even currently proposed standards for research fall short.

    But without such studies, no-one can ever really settle these questions about placebo.

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