91色情片

WANT TO devise a new form of alternative medicine? No problem. Here鈥檚 the
recipe.

Be warm, sympathetic, reassuring and enthusiastic. Your treatment should
involve physical contact, and each session with your patients should last at
least half an hour. Encourage your patients to take an active part in their
treatment and understand how their disorders relate to the rest of their lives.
Tell them that their own bodies possess the true power to heal. Make them pay
you out of their own pockets. Describe your treatment in familiar words, but
embroidered with a hint of mysticism: energy fields, energy flows, energy
blocks, meridians, forces, auras, rhythms and the like. Refer to the knowledge
of an earlier age: wisdom carelessly swept aside by the rise and rise of blind,
mechanistic science.

Oh, come off it, you鈥檙e saying. Something invented off the top of your head
couldn鈥檛 possibly work, could it? Well yes, it could鈥攁nd often well enough
to earn you a living. A good living if you are sufficiently convincing or,
better still, really believe in your therapy.

Many illnesses get better on their own, so if you are lucky and administer
your treatment at just the right time you鈥檒l get the credit. But that鈥檚 only
part of it. Some of the improvement really would be down to you. Not necessarily
because you鈥檇 recommended ginseng rather than camomile tea or used this crystal
as opposed to that pressure point. Nothing so specific. Your healing power would
be the outcome of a paradoxical force that conventional medicine recognises but
remains oddly ambivalent about: the placebo effect.

Placebos are treatments that have no direct effect on the body, yet still
work because the patient has faith in their power to heal. Most often the term
refers to a dummy pill, but it applies just as much to any device or procedure,
from a sticking plaster to a crystal to an operation. The existence of the
placebo effect implies that even quackery may confer real benefits, which is why
any mention of placebo is a touchy subject for many practitioners of
complementary and alternative medicine (CAM), who are likely to regard it as
tantamount to a charge of charlatanism. In fact, the placebo effect is a
powerful part of all medical care, orthodox or otherwise, though its role is
often neglected and misunderstood.

One of the great strengths of CAM may be its practioners鈥� skill in deploying
the placebo effect to accomplish real healing. 鈥淐omplementary practitioners are
miles better at producing non-specific effects and good therapeutic
relationships,鈥� says Edzard Ernst, professor of CAM at Exeter University. The
question is whether CAM could be integrated into conventional medicine, as some
would like, without losing much of this power.

At one level, it should come as no surprise that our state of mind can
influence our physiology: anger opens the superficial blood vessels of the face;
sadness pumps the tear glands. But exactly how placebos work their medical magic
is still largely unknown. Most of the scant research to date has focused on the
control of pain, because it鈥檚 one of the commonest complaints and lends itself
to experimental study. Here, attention has turned to the endorphins, natural
counterparts of morphine that are known to help control pain. 鈥淎ny of the
neurochemicals involved in transmitting pain impulses or modulating them might
also be involved in generating the placebo response,鈥� says Don Price, an oral
surgeon at the University of Florida who studies the placebo effect in dental
pain. 鈥淏ut endorphins are still out in front.鈥�

That case has been strengthened by the recent work of Fabrizio Benedetti of
the University of Turin, who showed that the placebo effect can be abolished by
a drug, naloxone, which blocks the effects of endorphins. Benedetti induced pain
in human volunteers by inflating a blood-pressure cuff on the forearm. He did
this several times a day for several days, using morphine each time to control
the pain. On the final day, without saying anything, he replaced the morphine
with a saline solution. This still relieved the subjects鈥� pain: a placebo
effect. But when he added naloxone to the saline the pain relief disappeared.
Here was direct proof that placebo analgesia is mediated, at least in part, by
these natural opiates.

Still, no one knows how belief triggers endorphin release, or why most people
can鈥檛 achieve placebo pain relief simply by willing it. Several labs are now
thinking of using brain imaging to study the neurobiology of the placebo effect
in more detail. 鈥淭he brain has already been imaged during drug-induced
analgesia,鈥� says Price. 鈥淭here鈥檚 going to be a race between laboratories to do
this experiment first for placebo analgesia.鈥�

Though scientists don鈥檛 know exactly how placebos work, they have accumulated
a fair bit of knowledge about how to trigger the effect. A London rheumatologist
found, for example, that red dummy capsules made more effective painkillers than
blue, green or yellow ones. Research on American students revealed that blue
pills make better sedatives than pink, a colour more suitable for stimulants.
Even branding can make a difference: if Aspro or Tylenol are what you like to
take for a headache, their chemically identical generic equivalents may be less
effective.

Special delivery

It matters, too, how the treatment is delivered. Decades ago, when the major
tranquilliser chlorpromazine was being introduced, a doctor in Kansas
categorised his colleagues according to whether they were keen on it, openly
sceptical of its benefits, or took a 鈥渓et鈥檚 try and see鈥� attitude (American
Journal of Psychiatry, vol 113, p 52). His conclusion: the more
enthusiastic the doctor, the better the drug performed. And this year Ernst
surveyed published studies that compared doctors鈥� bedside manners (The
Lancet, vol 357, p 757). The studies turned up one consistent finding:
鈥淧hysicians who adopt a warm, friendly and reassuring manner,鈥� he reported, 鈥渁re
more effective than those whose consultations are formal and do not offer
谤别补蝉蝉耻谤补苍肠别.鈥�

Warm, friendly and reassuring are precisely CAM鈥檚 strong suits, of course.
Many of the ingredients of that opening recipe鈥攖he physical contact, the
generous swathes of time, the strong hints of supernormal healing
power鈥攁re just the kind of thing likely to impress patients. It鈥檚 hardly
surprising, then, that complementary practitioners are generally best at
mobilising the placebo effect, says Arthur Kleinman, professor of social
anthropology at Harvard University.

鈥淭his doesn鈥檛 go down well in these communities because of the denigrating
connotations of placebos. It鈥檚 very threatening to people in those fields,鈥�
Kleinman says. 鈥淭he problem is that biomedicine has an extraordinarily negative
view of placebos. They鈥檙e treated as a nuisance rather than being seen as what
they really are.鈥� And what they are, according to Kleinman, is part of the
complex interaction of physiology, psychology and culture which underlies the
process of turning a sick person into a healthy one.

This, needless to say, is a world away from the mechanistic approach of most
conventional medicine, which has little to say about what people鈥檚 experience of
illness means to them. As Ernst puts it: 鈥淭he very popularity of complementary
medicine is a criticism of mainstream medicine. In the mainstream we have
sharper and sharper tools. But in terms of empathy, time, understanding and
touch we are losing out.鈥�

But even if many CAM therapies do get much of their power from the placebo
effect, it鈥檚 still important to ask whether there鈥檚 anything more to them than
that. To say鈥攁s many a CAM practitioner does鈥攖hat a treatment
鈥渨orks鈥� begs the question of how well it works. If a mantra-induced placebo
effect will ease the pain of my bad back, that鈥檚 good. But might something else
do it even better? A handful of aspirin, for example? If doctors had been
content to declare that a treatment works and leave it at that, orthodox
medicine would not have got far. We want to know not just what works, but what
works best. In answering that question, there鈥檚 no substitute for clinical
trials.

Yet it鈥檚 not easy to design those trials in a way that both CAM advocates and
conventional scientists will agree is fair. To give the clearest possible test
of the treatments in question, experimentalists want to randomly assign patients
to receive, say, aspirin or mantra therapy while rigorously holding all other
conditions constant. But CAM practitioners charge that this cookie-cutter
regularity is unfair to CAM therapies because it removes the individualised care
that is such a central feature of most of them. 鈥淏ecause I apply orthodox
research methods to complementary medicine, I鈥檝e been accused of stripping it of
what makes it work,鈥� says Ernst. 鈥淭hey say I鈥檓 throwing out the baby with the
bath water. I accept that this could be a danger. If a therapy works only as a
placebo then maybe one should keep science out of it. On the other hand this is
how science advances.鈥�

This problem of context extends far beyond the realm of research. It also
casts a shadow over attempts to integrate alternative therapies, with their
powerful placebo-invoking techniques, into mainstream medicine. In practice
this integration would mean, among other things, offering alternative medicine
on state systems like Britain鈥檚 National 91色情片 Service. To a limited but
growing extent this already happens: the NHS runs a couple of homeopathic
hospitals, and increasing numbers of family doctors invite aromatherapists,
acupuncturists, herbalists and others into their surgeries. Some doctors even
administer these treatments themselves.

But for much of CAM鈥攅specially techniques in which the placebo effect
accounts for most or perhaps all the benefit鈥攊ntegration might well be
counterproductive. After all, the value of CAM depends partly on its
unorthodoxy. Price talks of a 鈥渃lash of cultures鈥�. Would your free,
state-registered crystal therapist, pressed for time and perhaps wearing a
uniform just like other paramedical staff, still be able to mobilise as good a
placebo response? Ernst, for one, doubts it, and sees this as a powerful
argument against integration. 鈥淎lthough there is little evidence to support the
view, one intuitively feels that something exotic has a stronger placebo effect
than something bog standard. And some complementary therapies are very exotic,鈥�
he says.

Integration faces other obstacles, too. Doctors would face serious ethical
problems in recommending what they know to be placebo treatments to their
patients (see 鈥淎n ethical dilemma鈥�). And complementary practitioners would
likely be disparaged by their conventional counterparts, as they often are
today. With the growing emphasis on evidence-based medicine, installing a
roomful of radionics boxes or setting aside a clinic for dispensing Bach flower
remedies would be hard to justify, however much it might please the customers.
Integrated medicine 鈥渨ould have about as much validity as a hybrid of astronomy
and astrology鈥�, Neville Goodman, an anaesthetist in Bristol, wrote in the April
newsletter of 91色情片Watch.

91色情片care managers, too, may view such moves with some alarm. The addition
of a whole raft of new and time-consuming treatments could play havoc with
already overstretched budgets. In the long term, though, a few CAM techniques
might achieve integration. A study of low back pain by Britain鈥檚 Medical
Research Council, for instance, revealed that chiropractic compares favourably
with conventional hospital treatment in terms of cost and effectiveness
(British Medical Journal, vol 300, p 1431). It鈥檚 likely that chiropractic
treatment provides specific benefits over and above the placebo effect.

Even CAM techniques that do largely depend on their placebo value could
achieve the same cost-effectiveness. Indeed, for most of medicine鈥檚 history,
compassion, attention and tender loving care鈥攁ll big contributors to the
placebo effect鈥攚ere all that doctors had to offer. The advent of science
changed that, but in adopting their new role of body technician, doctors have to
a great extent dropped the traditional one of healer: the non-specific but still
valuable business of caring. Most doctors would now be faintly embarrassed by
the suggestion that 鈥渉ealing鈥� might be part of their job description. It sounds
a bit pre-scientific. But that鈥檚 what most CAM practitioners still offer, and
they are certainly not embarrassed by the idea.

A professor of surgery with a confident manner, an expensive suit and an
international reputation who sees you privately and guarantees to solve your
problem with a costly operation may still be unrivalled as a source of placebo
power. But most doctors are beaten hands down by countless alternative
practitioners who might not know a lymphocyte from a lump of cheese. What they
do know is how to make you feel better. And that鈥檚 a big part of the battle.

For doctors who take their medical ethics seriously, the placebo effect can
pose a dilemma. Imagine that a patient turns up asking asking for advice about a
remedy which is harmless but, in the doctor鈥檚 view, also useless. If there鈥檚 a
proven orthodox cure for the complaint, the correct course of action is clear:
steer the patient towards that treatment.

But suppose there is no orthodox treatment, or the patient has tried whatever
there is and not responded. Should the doctor stay true to science and declare
that the remedy is a waste of time, thereby undermining any beneficial placebo
effect it might have? Or should scientific purity be sacrificed in favour of an
enthusiastic but dishonest endorsement which might boost the treatment鈥檚 placebo
action? Could the doctor even argue that endorsement would be legitimate because
the remedy would in fact have some benefit, thanks to the placebo effect?

In practice, many doctors try to avoid betraying either their allegiance to
science or their ethical duty to tell the truth. One escape route is to find a
form of words which wriggles round the problem. Something like, 鈥淚鈥檝e had no
first-hand experience of this treatment, but I know that some people find it
rewarding.鈥� That鈥檚 what you call the art of medicine.