DON’T BE FOOLED BY PLACEBOS
Medicine used to be easy. Through (conventional) medicine we have successfully eradicated many once commonplace and potentially fatal illnesses. At our disposal we now have a veritable army of drugs to ease pain, make us immune to diseases and thwart the progress of degenerative conditions. We have surgical techniques that can mend and replace parts of us that wear out or become damaged due to illness. Yet all is not well in this Utopia of Man conquering disease and illness.
As I write this article (May 2013) a new strain of Bird Flu, H7N9, is beginning to stir the Worldwide medical community amid fears that this could be the ‘big one’. Thirty years on from its first appearance, HIV still does not have a robust cure. It is commonplace to hear that hospital wards are closed due to anti-biotic resistant infections. Drugs are becoming increasingly expensive to produce – we are never far from a heartstring-pulling story of some new ‘wonder’ drug being available and yet too expensive to be prescribed to patients. We are living longer than ever before, but as a consequence we are exposing ourselves to an increasing number of conditions as our bodies and our body chemistry wear out.
Proponents of conventional medicine will argue that it is just a matter of time – drugs for the currently incurable WILL be found, we just need more time. All we need is more time to get inside the agents that cause these conditions, more time to delve ever deeper into their biochemistry, more time to improve our understanding of our own physiology and then modern medicine will prevail once more.
What I would like to argue in this article is that our current conventional ways of thinking of health are perhaps running out of steam and now need to make room for other ways of thinking. What I shall then argue is that some of these ‘other ways‘ are not new at all – not new because other branches of science have already learnt to embrace these methods and not new because many alternative models of health and well-being have been adopting these approaches for, in some cases, millennia.
THE CLOCKWORK MODEL OF THE WORLD
“My name is Phil Nuttridge and I have a degree in Biophysics”.
Whilst that may not be your usual sort of confessional statement, I think it is going to be an important one here. Biophysics is a wonderful subject (of course I am going to say that), which transcends traditional boundaries between the physics of the material world and the diversity of living systems. As a graduate of Biophysics I find it quite natural to inject a bit of mathematical thinking into any discourse on living systems, in particular models of health and wellbeing. Whilst that may be alien territory for most of my intended audience here, I am asking your forgiveness in advance for doing just that in this article. Please take it on trust that the journey is worth it!
Let me take you back to physics a la Seventeenth Century. The great scientists of that time such as Galileo and Kepler were making significant in-roads into our understanding of the physical universe. A little while earlier, Copernicus had radically changed things by putting the Sun at the centre of our part of the cosmos; what Galileo and Kepler did then was to deduce the physical laws governing the motion of these celestial bodies. Their legacy was to give us the idea of a clockwork universe – understand the laws of planetary motion sufficiently and then you can ‘crank the handle’ of this clockwork universe to predict where the planets will be at any point in the future.
To the Human mind, there is something very satisfying about this. Being able to disassemble the components of the world around us, understand the laws controlling the behaviour of those components and then reassemble them to understand the ‘whole’ is surely testament to Man’s supremacy of the world around him?
The clockwork model of the world very successfully unlocked our understanding of many aspects of the physical world around us and not just the movement of the cosmos. For nearly two centuries it ruled supreme. Its proponents were, and indeed still are, hailed as the ‘greats’ of the early scientific movement. However, by the early twentieth century Einstein and his contemporaries were beginning to challenge the supremacy of the clockwork model. Observations were stacking-up that just did not fit with a clockwork world. At first it was the observations that were challenged rather than the clockwork model as, after all, the clockwork model had been so successful for so long. It took some of the greatest scientific minds of the twentieth century to formulate a robust challenge to the clockwork model and spawn what we now call modern physics. A century on, and modern physics embraces the strange world of strings, bosons, quanta and uncertainty.
What I would like to argue is that current medical thinking is now at a similar turning point.
Back in the Seventeenth century the success of the clockwork model, led to its extension to other aspects of the world around us. The philosopher Descartes is attributed as the founder of the clockwork or mechanical model of the human body. He was the first to consider living things as little more than automata or mechanical machines the components of which would one day be sufficiently understood in sufficient detail so that all aspects of the ‘human condition’ would be explained. Although we have perhaps watered-down our thinking a little in the intervening centuries, particularly in respect of us being little more than automata, this mechanical approach still dominates medical thinking today.
Let me rephrase the Descartes model and instead call it the reductionist/mechanist model of medicine. By reductionist/mechanist I mean an approach that assumes if we know enough about how the individual cellular components and chemicals inside a living system work (the ‘reductionist’ bit), then we can scale-up this knowledge and understand how living organisms such as you and I function as a whole (the ‘mechanist’ bit). Medical techniques based on reductionist/mechanist principles rely heavily on drugs that work at the molecular level and whose benefits are then scaled-up to whole human beings in a similar manner.
I am not inherently against reductionism. Reductionism has given us great insights into the workings of many aspects of the human body. Those parts that can be considered as mechanical (joints, heart valves, eyes and ears for example) respond well to the mechanical type treatments that reductionism would offer. Much of the sphere of my own work as a Manual Therapist relies on what we have learnt about muscle and joint function at a reductionist level and as such responds well to methods developed on the back of reductionist/mechanist research.
Also, for us humans, reductionism/mechanism is intuitive – you show me a little boy or girl who has not dismantled a toy (probably a brother’s or sister’s favourite toy) in order to ‘understand’ better how it works. It is part of the human psyche to disassemble something to understand better how it is assembled and how that assembly operates. What I am arguing for is that when something is imbued with the quality we call ‘life’, then that object can no-longer be considered as a purely mechanical object, merely the sum of its mechanical components. There are characteristics of living things that cannot be disassembled, that cannot be found in the disassembled components or deduced from reassembling those components. When it comes to living things, the whole is most definitely greater than the sum of its parts.
But maybe even that latter part (the bit about the whole being greater than the sum) is in our psyche too. When I wrote that previous paragraph, I just added the bit about ‘a brother’s or sister’s favourite toy’ as a bit of humour. Actually, now I have thought about it, perhaps it was more than that. Perhaps we do intuitively understand that once something has been disassembled and reassembled it is no longer the same. As a child, we would rather take apart something that is not precious to us because we know that when we reassemble it, it is not truly the same as it was. And what is true of inanimate toys, is of course certainly going to be true of living things.
So if I am suggesting that reductionist/mechanist models of medicine are running out of steam, what might the alternatives look like. For me, the opposite of reductionism in medicine shall equate to the body of holistic alternative and complementary therapies. The existence of such holistic approaches to health is often to the annoyance of the conventional medical fraternity. The reductionist approach to medicine has not yet found robust explanations to how all or possibly any of these approaches work (or is it because the medical fraternity have not been looking for explanations, something I shall explore later) and it is an essential part of the reductionist ideal that if no explanation can be found at the molecular or reduced level, then such approaches cannot work. For example, if a reductionist cannot measure or understand how an acupuncturist’s needle affects the chemical functioning of a molecule or an individual cell, then that same reductionist cannot extrapolate-up the benefits of acupuncture on a whole human being. Often any holistic therapy benefits observed in patients will be dismissed by the medical fraternity because they do not have a reductionist explanation of how they could work. Seeing is not believing – apparently.
THE BLUEPRINT OF LIFE
One of the holy grails of reductionist medical research is that one day we should understand to such a great level of detail the body’s molecular functioning that we should then be able to ‘design’ drugs at a molecular level to deal with any ailment. Unlock the destiny of every molecule in the human body and how that destiny is impacted by illness, we then unlock the detail of how to overcome any illness that can beset us, or so the story goes. The centre-piece of this was the creation of the Human Genome Project.
On June 26 2000, President Bill Clinton took to the stage on the publication day of the first draft of the Human Genome Project. This project, started in 1990 and with a (then) budget of over $3 billion, was created to map every chemical genetic instruction of the human genome. I shan’t get too technical here, but essentially within our 46 chromosomes and the DNA contained therein, are the chemical instructions used to create each one of us (this is of course in the words of the reductionist fraternity). Once we had the technology to delve into this, it became the ‘space race‘ of the medical world to elucidate all of these instructions and create the complete map of how a human being is made. President Clinton told us:
“We are here today to celebrate the completion of the first survey of the entire human genome. Without a doubt this is the most important, most wondrous map ever produced by mankind. It will revolutionise the diagnosis, prevention and treatment of most, if not all human diseases. Humankind is on the verge of gaining immense, new power to heal”
I don’t know about you, but 13 years on, I feel I am still waiting for this immense new power to heal!
So what went wrong? Before I get on my reductionist versus holistic approach hobby horse, here are some interesting statistics. At the start of the Human Genome Project it was anticipated that there would be around 100,000 genes in our genome. Disappointingly the number turned out to be only around 23,000. If you are a reductionist/mechanist, this is fundamentally troubling. If the genome is truly the repository for the biochemical instructions to make us, then of course there needs to be enough instructions to account for the complexity of a human being. Whilst 23,000 instructions may seem a lot, consider by comparison that there are 26,000 genes in a sea urchin’s genome and 38,000 in some species of rice! A parallel project to map the genome of chimpanzees and compare it to our genome, set-out to discover the biochemical (reductionist) prerequisites that make us different from chimpanzees. When the project completed, the chimpanzee genome was found to be so similar to our own that the director of the chimpanzee project concluded: ‘We cannot see in this why we are so different from chimpanzees’. Unlocking every molecule and the instructions to create those molecules is perhaps going to be less revealing than we thought.
Such a dead end has to be fundamentally troubling to the reductionist/mechanist fraternity. Unlocking the genome is the ultimate pathway available to reductionists – there are no deeper levels to explore beyond that. If that level of reductionism fails to deliver an understanding that leads to a ‘new power to heal’ then maybe reductionism itself cannot deliver this new power.
At the danger of repeating myself, let me make one final comparison with my earlier discourse on the clockwork model of the cosmos. The use of the Human Genome has a parallel to where physics was before the turn of the 20th century. Mechanists up to that time thought of the cosmos as being like a clockwork model, working according to precise and immutable laws and rules. If we just knew enough about the starting conditions to feed-into these laws and rules we could thereby predict everything about the future of the cosmos. Similarly, if we could map-out the details of the mechanical wheels and cogs of the human body as encoded in our genome, then in a similar clockwork fashion we could understand the workings of the human body in health and in illness. Physics, when it reached its crisis point, adapted and embraced the strange new world of quantum mechanics. Perhaps medicine has to find a similar new strategy.
As I said earlier, I am not against reductionist/mechanist medicine as it DOES work in many situations, much of the time. What I am arguing is that, just like the clockwork mechanics of the cosmos, medicine is now facing challenges and observations that just don’t quite fit the model and that force us to rethink where medicine is heading in the twenty-first century.
SO WHAT’S THE EVIDENCE?
So what are these observations that challenge conventional medical thinking? To my mind (of course) these are many and various. My thrust here though will be a look at the role of placebos in medicine.
I would imagine that most of my intended audience here are familiar with the concept of the placebo. In fact, I suspect many of the alternative and complementary therapists reading this may have had their modalities of treatment dismissed as nothing more than the placebo effect wrapped-up in non-scientific mumbo-jumbo (or is it just me smarting from that one?).
The Wikipedia definition of a placebo is:
….a simulated or otherwise medically ineffectual treatment for a disease or other medical condition intended to deceive the recipient. Sometimes patients given a placebo treatment will have a perceived or actual improvement in a medical condition, a phenomenon commonly called the placebo effect.
Already I am getting a bit animated. Just consider that – a treatment that is medically ineffectual that will have a perceived or actual improvement in a medical condition. If a treatment gives an improvement in a medical condition, can you still honestly call it medically ineffectual? Perhaps I can be assertive here a recast that part of the definition in terms of my foregoing discussions. A placebo is then a treatment that does not fit the reductionist/mechanist approach to medicine and yet in some cases brings about improvement in a medical condition. Now that makes me feel a bit happier. And what about ‘actual’ versus ‘perceived’ improvement in a condition? If a patient perceives an improvement in his or her condition, is that not an improvement? And so, if the placebo effect brings about an improvement in a medical condition, does that not make it an effective treatment?
The placebo (in the strict sense that is intended to deceive a recipient) is the mainstay of the Randomised Clinical Trial (RCT), the main route through which drugs or procedures are tested before being prescribed. In a RCT patients are exposed either to the drug/procedure being tested or a placebo; in the most robust RCTs neither the prescribing practitioner nor the patient knows whether the treatment being administered is the ‘real’ one or the placebo. Such RCTs are known as double blind. If you are a reductionist/mechanist then the interpretation of such trials is clear – if the drug or procedure being tested is effective, then those patients receiving it shall show significantly better improvements in their conditions than those receiving the placebo. If the placebo and the drug perform equally well, then there is no case for the effectiveness of the drug/procedure being tested.
Unfortunately, what gets in the way are peoples’ emotions, beliefs and hopes. Now that is VERY troubling for the reductionists/mechanists. If we have drugs and procedures developed and working at the reductionist and mechanical level, then the mechanistic model just has no latitude to allow for these touchy-feely concepts. Allow me to present some of the evidence of this.
Firstly let us look at Prozac. Worldwide sales of Prozac are huge – $2 billion annually at one estimate. Because it is ‘out there’ we would expect therefore that RCTs testing its effectiveness would show that it is significantly better than a placebo. At first glance the results of the RCTs would indeed suggest that. However there is a problem. Prozac has well-documented side effects such as nausea and insomnia. As such, a practitioner prescribing Prozac in a RCT may very quickly be able to determine whether they are indeed prescribing Prozac or the placebo. Remember, one of the key aspects of a robust RCT is that neither practitioner nor patient know if they are using the real drug. Ask the patient if they experienced either side effect and bam, you know or at least strongly suspect whether it was indeed Prozac that was prescribed. This is known as ‘breaking the blind’. Of course in a reductionist/mechanist model that should make absolutely no difference to the outcome. However, the stats do not support that. Making no allowance for ‘breaking the blind’, Prozac does indeed out-preform a placebo. However, if you eliminate data where the prescribing practitioner successfully deduced that they were in fact prescribing Prozac, then Prozac barely out-performs the placebo. Pitch Prozac against a placebo that also causes nausea and vomiting and again there is little difference between the real drug and the placebo.
If Prozac works at a reductionist/mechanist level, then how can the practitioner knowing which is being prescribed make a difference? Can it really be that the prescribing practitioner’s beliefs and hopes make a difference to the effectiveness of a treatment?
Let me throw another example at you. In the late Naughties, analysis showed that placebos are becoming increasingly effective in clinical trials, particularly in the United States. Let me be clear here – I am not just saying that in clinical trials since the start of this century the gap between the drugs being tested and placebos has narrowed (which is certainly true) but more specifically that placebos perform better now against a range of medical conditions than ever they did before. What is more, this effect is more noticeable in the United States.
The reason that has been suggested for this is also testament to the success of the pharmaceutical industry. Since 1997 drug companies in the United States have been able to market their products directly to their ‘consumers’, the American people. Thanks to the power of the marketing machines of the pharmaceutical industry, Americans now see images of happy, healthy, smiley people and it is all thanks to the latest wonder drugs. The American populace therefore has a heightened expectation from the output of drug companies – put these people in clinical trials and even if they are receiving the placebo, their belief in the power of drugs can make those placebos work more effectively than ever before.
So, we have evidence that the hopes and expectations of practitioners and patients alike can make profound differences to the effectiveness of treatment. No reductionist/mechanist model of medicine I know of can account for that.
Let me give you one more example to challenge the accepted model of medicine. Clinical trials of the drug Oxazepam have shown that it is more effective at treating anxiety when the pills are dyed green and yet more effective at treating depression when dyed yellow. The same chemical compound targeting the same biochemical pathways but its effect depending on its colour? Unless we are suggesting that the dyes being used are the ‘active’ ingredient, then this again has to be very troubling to the reductionist/mechanists.
So how do we make sense of this and what other models of medicine are available to account for this?
I shall address both of these questions in the second part to this article. I shall look at how some exciting new developments in mathematics might be showing the future direction for medicine and how some of the most ancient philosophies of health and well-being have been embracing such thinking for millennia.
Article taken from: www.holistictherapistmagazine.com