Читать книгу Bad Science - Ben Goldacre - Страница 26

Even if they do nothing, doctors, by their manner alone, can reassure. And even reassurance can in some senses be broken down into informative constituent parts. In 1987, Thomas showed that simply giving a diagnosis—even a fake ‘placebo’ diagnosis—improved patient outcomes. Two hundred patients with abnormal symptoms, but no signs of any concrete medical diagnosis, were divided randomly into two groups. The patients in one group were told, ‘I cannot be certain of what the matter is with you,’ and two weeks later only 39 per cent were better; the other group were given a firm diagnosis, with no messing about, and confidently told they would be better within a few days. Sixty-four per cent of that group got better in two weeks.

This raises the spectre of something way beyond the placebo effect, and cuts even further into the work of alternative therapists: because we should remember that alternative therapists don’t just give placebo treatments, they also give what we might call ‘placebo explanations’ or ‘placebo diagnoses’: ungrounded, unevidenced, often fantastical assertions about the nature of the patient’s disease, involving magical properties, or energy, or supposed vitamin deficiencies, or ‘imbalances’, which the therapist claims uniquely to understand.

And here, it seems that this ‘placebo’ explanation—even if grounded in sheer fantasy—can be beneficial to a patient, although interestingly, perhaps not without collateral damage, and it must be done delicately: assertively and authoritatively giving someone access to the sick role can also reinforce destructive illness beliefs and behaviours, unnecessarily medicalise symptoms like aching muscles (which for many people are everyday occurrences), and militate against people getting on with life and getting better. It’s a very tricky area.

I could go on. In fact there has been a huge amount of research into the value of a good therapeutic relationship, and the general finding is that doctors who adopt a warm, friendly and reassuring manner are more effective than those who keep consultations formal and do not offer reassurance. In the real world, there are structural cultural changes which make it harder and harder for a medical doctor to maximise the therapeutic benefit of a consultation. Firstly, there is the pressure on time: a GP can’t do much in a six-minute appointment.

But more than these practical restrictions, there have also been structural changes in the ethical presumptions made by the medical profession, which make reassurance an increasingly outré business. A modern medic would struggle to find a form of words that would permit her to hand out a placebo, for example, and this is because of the difficulty in resolving two very different ethical principles: one is our obligation to heal our patients as effectively as we can; the other is our obligation not to tell them lies. In many cases the prohibition on reassurance and smoothing over worrying facts has been formalised, as the doctor and philosopher Raymond Tallis recently wrote, beyond what might be considered proportionate: ‘The drive to keep patients fully informed has led to exponential increases in the formal requirements for consent that only serve to confuse and frighten patients while delaying their access to needed medical attention.’

I don’t want to suggest for one moment that historically this was the wrong call. Surveys show that patients want their doctors to tell them the truth about diagnoses and treatments (although you have to take this kind of data with a pinch of salt, because surveys also say that doctors are the most trusted of all public figures, and journalists are the least trusted, but that doesn’t seem to be the lesson from the media’s MMR hoax).

What is odd, perhaps, is how the primacy of patient autonomy and informed consent over efficacy—which is what we’re talking about here—was presumed, but not actively discussed within the medical profession. Although the authoritative and paternalistic reassurance of the Victorian doctor who ‘blinds with science’ is a thing of the past in medicine, the success of the alternative therapy movement—whose practitioners mislead, mystify and blind their patients with sciencey-sounding ‘authoritative’ explanations, like the most patronising Victorian doctor imaginable—suggests that there may still be a market for that kind of approach.

About a hundred years ago, these ethical issues were carefully documented by a thoughtful native Canadian Indian called Quesalid. Quesalid was a sceptic: he thought shamanism was bunk, that it only worked through belief, and he went undercover to investigate this idea. He found a shaman who was willing to take him on, and learned all the tricks of the trade, including the classic performance piece where the healer hides a tuft of down in the corner of his mouth, and then, sucking and heaving, right at the peak of his healing ritual, brings it up, covered in blood from where he has discreetly bitten his lip, and solemnly presents it to the onlookers as a pathological specimen, extracted from the body of the afflicted patient.

Quesalid had proof of the fakery, he knew the trick as an insider, and was all set to expose those who carried it out; but as part of his training he had to do a bit of clinical work, and he was summoned by a family ‘who had dreamed of him as their saviour’ to see a patient in distress. He did the trick with the tuft, and was appalled, humbled and amazed to find that his patient got better.

Although he continued to maintain a healthy scepticism about most of his colleagues, Quesalid, to his own surprise perhaps, went on to have a long and productive career as a healer and shaman. The anthropologist Claude Lévi-Strauss, in his paper ‘The Sorcerer and his Magic’, doesn’t quite know what to make of it: ‘but it is evident that he carries on his craft conscientiously, takes pride in his achievements, and warmly defends the technique of the bloody down against all rival schools. He seems to have completely lost sight of the fallaciousness of the technique which he had so disparaged at the beginning.’

Of course, it may not even be necessary to deceive your patient in order to maximise the placebo effect: a classic study from 1965—albeit small and without a control group—gives a small hint of what might be possible here. They gave a pink placebo sugar pill three times a day to ‘neurotic’ patients, with good effect, and the explanation given to the patients was startlingly clear about what was going on:

A script was prepared and carefully enacted as follows: ‘Mr. Doe … we have a week between now and your next appointment, and we would like to do something to give you some relief from your symptoms. Many different kinds of tranquilizers and similar pills have been used for conditions such as yours, and many of them have helped. Many people with your kind of condition have also been helped by what are sometimes called ‘sugar pills’, and we feel that a so-called sugar pill may help you, too. Do you know what a sugar pill is? A sugar pill is a pill with no medicine in it at all. I think this pill will help you as it has helped so many others. Are you willing to try this pill?’

The patient was then given a supply of placebo in the form of pink capsules contained in a small bottle with a label showing the name of the Johns Hopkins Hospital. He was instructed to take the capsules quite regularly, one capsule three times a day at each meal time.

The patients improved considerably. I could go on, but this all sounds a bit wishy-washy: we all know that pain has a strong psychological component. What about the more robust stuff: something more counterintuitive, something more … sciencey?

Dr Stewart Wolf took the placebo effect to the limit. He took two women who were suffering with nausea and vomiting, one of them pregnant, and told them he had a treatment which would improve their symptoms. In fact he passed a tube down into their stomachs (so that they wouldn’t taste the revolting bitterness) and administered ipecac, a drug that which should actually induce nausea and vomiting.

Not only did the patients’ symptoms improve, but their gastric contractions—which ipecac should worsen—were reduced. His results suggest—albeit it in a very small sample—that a drug could be made to have the opposite effect to what you would predict from the pharmacology, simply by manipulating people’s expectations. In this case, the placebo effect outgunned even the pharmacological influences.