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For years, Ted Kaptchuk performed
acupuncture at a tiny clinic in Cambridge,
a few miles from his current
office, at the Harvard Medical School.
He opened for business in 1976, on a
street so packed with alternative healers
that it was commonly referred to as
“quack row.” Kaptchuk had just returned
from Asia, where, as an exiled alumnus
of the turbulent sixties, he had spent four
years honing his craft. “There were lots
of alternatives on that street in those
days, but no practitioners of Chinese
medicine,” Kaptchuk, who is sixty-four
and still lives in the neighborhood, told
me recently as we sipped (Chinese) tea
in the study of his house. “The area is a
little too L. L. Bean for my taste now,”
ANNALS OF SCIENCE
THE POWER OF NOTHING
Could studying the placebo effect change the way we think about medicine?
BY MICHAEL SPECTER
he said. “It was a different place then.”
Not long after Kaptchuk arrived in
Boston, he treated an Armenian woman
for chronic bronchitis. A few weeks later,
she showed up in his office with her husband,
who had a Persian rug slung over
his shoulder. He nodded to Kaptchuk and
said, “This is for you.” Kaptchuk accepted
the rug, which he still owns, but had no
idea what he had done to earn it. “Oh,
doctor, you have been so wonderful,” the
woman told him. “You cured me. I was
about to have an operation on my ovaries
and the pain went away the day you saw
me.” Kaptchuk never spoke to the woman
again, but he has been unable to get her
out of his mind. “There was no fucking
way needles or herbs did anything for that
Scientists are now seriously investigating—and debating—our response to sugar pills.
woman’s ovaries,” he told me, still looking
mystified, thirty-five years later. “It had to
be some kind of placebo, but I had never
given the idea of a placebo effect much attention.
I had great respect for shamans—
and I still do. I have always believed there
is an important component of medicine
that involves suggestion, ritual, and belief—all
ideas that make scientists scream.
Still, I asked myself, Could I have cured
her? How? I mean, what could possibly
have been the mechanism?”
At the time, few serious scientists
would have entertained such questions,
let alone allowed words like “ritual” and
“belief ” to seep into a conversation about
medicine. Placebos had a bad name,
which is not surprising, since they have
been used primarily to deceive people. In
clinical trials, if a drug and a sugar pill
produce similar results, the drug has generally
been considered worthless. But the
definition of medical treatment is changing,
and so are attitudes about placebos.
This year, Harvard created an institute
dedicated wholly to their study, the Program
in Placebo Studies and the Therapeutic
Encounter. It is based at the Beth
Israel Deaconess Medical Center and
Kaptchuk was named its director. He
has already recruited leading researchers
from around the world, in disciplines as
diverse as neuroanatomy and semiotics.
The program was formed to explore an
idea that even twenty years ago would
have seemed preposterous: that placebos—given
deliberately—might be deployed
in clinical practice. As medicine.
Kaptchuk has no shortage of critics.
They acknowledge the power of the
mind to influence health but question
the rigor of studies suggesting that placebos
could possibly prove as valuable as
drugs. Indeed, the idea of dispensing
sugar pills is jarring even to those who,
like Kaptchuk, are enthusiastic about it.
After all, placebos have almost always
been defined as exactly what medicine
is not. “I realized long ago that at least
some people respond even to the suggestion
of treatment,” Kaptchuk said.
“We know that. We have for centuries.
But unless we figured out how that process
worked, and unless we did it with
data that other researchers would consider
valid, nobody would pay attention
to a word we said.”
The research has been propelled in
large measure by the emerging discipline
ANDERS WENNGREN
30 THE NEW YORKER, DECEMBER 12, 2011
of neuroimaging—which, like a live satellite
feed from inside the human body,
permits scientists to track precisely how
a person reacts to a drug (or a placebo) as
soon as he takes it. An injection of saline,
for example, that has been described as a
drug not only will reduce symptoms of
Parkinson’s disease but can help a patient
produce more of the dopamine that
the disease destroys. Results like those
have provided scientists with chemical
evidence of something they had long
suspected: simply believing in a treatment
can be as effective as the treatment
itself. In several recent studies, placebos
have performed as well as drugs that
Americans spend millions of dollars on
each year.
Transforming interesting laboratory
findings into medicine is never simple,
however, particularly when those findings
involve fake pills and sham injections.
Some people clearly respond
better to placebos than others, though
we don’t know why; some illnesses and
afflictions are more amenable to suggestion
than others; and many of the most
intriguing findings are tenuous. Even so,
the recent research is difficult to dismiss.
Through conditioning techniques, for
example, our brain can “learn” different
kinds of placebo effects: people first given
morphine and then a placebo have one
neurochemical response, while people
who take ibuprofen followed by a placebo
have another. Different “doses”
cause different reactions, and studies
have demonstrated that people who
suffer from headaches and consume aspirin
regularly can associate the shape,
the color, and even the taste of a pill with
a decrease in pain. The value of treatments
like those—which have none of
the side effects of drugs—would be immense,
but placebos are not pharmaceuticals,
and no reputable researcher has
suggested that they will soon be for sale
at your local pharmacy.
Kaptchuk acknowledges that placebos
are not magic potions. “Placebos
don’t shrink tumors,” he said. “They
don’t make blind people see. If you are
paralyzed, they won’t help you walk.” He
deplores the grandiose claims of alternative
medicine and prefers to rely on data.
“Ultimately, I am not a zealot or even a
true believer,” he said. “I am sure that I do
not understand the placebo effect. I ask
questions, hopefully valuable questions,
and we will see where the research lands.”
Kaptchuk practiced acupuncture for
half his adult life. But he stopped twenty
years ago. Despite the popularity of acupuncture,
clinical studies continually fail
to demonstrate its effectiveness—a fact
that Kaptchuk doesn’t dispute. I asked
him how a person who talks about the
primacy of data and disdains what he
calls the “squishiness” of alternative medicine
could rely so heavily on a therapy
with no proven value. Kaptchuk smiled
broadly. “Because I am a damn good
healer,” he said. “That is the difficult
truth. If you needed help and you came
to me, you would get better. Thousands
of people have. Because, in the end, it
isn’t really about the needles. It’s about
the man.”
For most of human history, placebos
were a fundamental tool in any physician’s
armamentarium—sometimes the
only tool. When there was nothing else
to offer, placebos were a salve. The word
itself comes from the Latin for “I will
please.” In medieval times, hired mourners
participating in Vespers for the Dead
often chanted the ninth line of Psalm
116: “I shall please the dead in the land
of the living.” Because the mourners were
hired, their emotions were considered insincere.
People called them “placebos.”
The word has always carried mixed
connotations. Thomas Jefferson wrote
approvingly of what he called a “pious
fraud,” and noted that “one of the most
successful physicians I have ever known
has assured me that he used more bread
pills, drops of coloured water, and powders
of hickory ashes, than of all other
medicines put together.” But, as increasingly
specific knowledge about human
anatomy emerged, people began to demand
scientific answers to medical questions.
Knowledge displaced faith, and
human health improved rapidly. Antibiotics
are real; placebos are not.
The first publicly acknowledged placebo-controlled
trial—and still among
the most remarkable—took place at the
request of King Louis XVI, in 1784,
under the direction of Benjamin Franklin,
then the American Ambassador to
France. The German physician Franz
Anton Mesmer had become famous in
Vienna for a new treatment he called
“animal magnetism,” and he claimed to
have discovered a healing fluid that
THE NEW YORKER, DECEMBER 12, 2011 31
could “cure” many ailments. Mesmer
became highly sought after in Paris,
where he would routinely “mesmerize”
his followers—one of whom was Marie
Antoinette. The King wasn’t buying it,
however, and he asked a commission of
the French Academy of Sciences to
look into the claims. (The members included
Franklin, the chemist Antoine
Lavoisier, and Joseph Guillotin—who
invented the device that would eventually
separate the King’s head from his
body.) The commission replicated some
of Mesmer’s sessions, and, in one case,
asked a young boy to hug magnetized
trees that were presumed to contain the
healing powers invoked by Mesmer. He
did as directed and responded as expected:
he shook, convulsed, and
swooned. The trees, though, were not
magnetic, and Mesmer was denounced
as a fraud. Placebos and lies were intertwined
in the public mind.
It was another hundred and fifty years
before scientists began to focus on the
role that emotions can play in healing.
During the Second World War, Lieutenant
Colonel Henry Beecher—who
went on to become the first chairman of
the anesthesia department at Massachusetts
General Hospital—attempted to
assess the degree to which the severity
of a soldier’s injuries corresponded to
the amount of pain he felt. In Europe,
Beecher met with more than two hundred
soldiers, gravely wounded but still
coherent enough to talk; he asked each
man if he wanted morphine. Seventyfive
per cent declined.
Beecher was astounded. He knew
from his experience before the war that
civilians with similar injuries would have
begged for morphine, and he had seen
healthy soldiers complain loudly about
the pain associated with minor inconveniences,
like receiving vaccinations. He
concluded that the difference had to do
with expectations; a soldier who survived
a terrible attack often had a positive outlook
simply because he was still alive.
Beecher made a simple but powerful observation:
our expectations can have a
profound impact on how we heal.
Armed with this information, and
with his conviction that the placebo
effect could be harnessed to help relieve
suffering, Beecher returned to the United
States and continued his research. In
1955, he published an article called “The
Powerful Placebo,” in which he wrote
that “placebos have a high degree of therapeutic
effectiveness in treating subjective
responses.” The paper has been cited
more than a thousand times by other scientists,
and Beecher’s conclusion—that
the placebo effect plays a critical role
in almost any medical intervention—
influenced much of what has followed in
clinical research. His basic supposition
was correct: emotions and expectations
can affect our perception of pain.
Before Beecher’s work, new drugs
were tested in a haphazard manner; since
then, they have always been compared
with a placebo or with another drug. But
Beecher’s methodology was deeply
flawed. Although he reported that placebos
were effective more than a third of
the time, he shrugged off a phenomenon
known as “regression to the mean.” Over
time, the condition of most patients
improves, with or without treatment.
A person who enrolls in a clinical study
when he is feeling particularly bad is
likely to improve solely as a result of the
natural course of the illness, not because
he was given a placebo. (And people
often enroll in such studies when they are
sickest.) A patient who knows that he is
in a study also may expect a better therapeutic
result than one who doesn’t. If you
believe that doctors are particularly attentive,
you can get better more rapidly, even
if they aren’t. This is known as the Hawthorne
effect. (There is also a “nocebo
effect.” Expecting a placebo to do harm
or cause pain makes people sicker, not
better. When subjects in one notable
study were told that headaches are a side
effect of lumbar puncture, the number of
headaches they reported after the study
was finished increased sharply.)
For years, researchers could do little
but guess at the complex biology of the
placebo response. A meaningful picture
began to emerge only in the nineteenseventies,
with the discovery of endorphins:
substances secreted in the brain
that are chemically similar to opiates like
morphine and heroin. The discovery led
to the novel idea that, in effect, the brain
produces its own pharmacy. In 1978,
three scientists from the University of
California at San Francisco—Jon Levine,
Newton Gordon, and Howard Fields—
decided to investigate whether endorphins
might explain why patients who
received placebos often reported a
significant reduction in pain. People recovering
from dental surgery were told
that they were about to receive a dose of
morphine, saline, or a drug that might
increase their pain. By then, researchers
had learned not only about the nocebo
effect but that a suggestion of relief will
often trigger the production of endorphins,
so they were not surprised that patients
receiving saline reported reduced
pain.
What came next, however, fundamentally
reshaped the field. The researchers
dismissed the subjects who received
morphine and then divided the
remaining participants into those who
responded to the placebo and those who
didn’t. Then they introduced Naloxone
into patients’ I.V. drips. Naloxone was
developed to counteract overdoses of
heroin and morphine. It works essentially
by latching onto, and thus locking
up, key opioid receptors in the central
nervous system. The endorphins that we
secrete attach themselves to the same receptors
in the same way, so Naloxone
blocks them, too. The researchers theorized
that, if endorphins had caused the
placebo effect, Naloxone would negate
their impact, and it did. The Naloxone
caused those who responded positively to
the placebos to experience a sharp increase
in pain; the drug had no effect on
the people who did not respond to the
placebo. The study was the first to provide
solid evidence that the chemistry behind
the placebo effect could be understood—and
altered.
“It was one of those studies that make
the scales fall from your eyes,” Kaptchuk
told me. “I had just started to think about
the placebo effect—scientifically and historically.
And here comes this paper that
says that, even if it’s all in your head, there
is still a biological mechanism driving
these reactions. It was very exciting.”
Kaptchuk assumed that the results
would add legitimacy to the field.
He was wrong. “Things are better than
they were,” he said. “But even now, you
know, people at Harvard talk about placebos
the way the Popes used to talk
about medicine. They declared that Jews
were not allowed to treat Christians—
not because they were not good doctors
but because it would have been ethically
wrong. These are ethical judgments masquerading
as science. Because from the
32 THE NEW YORKER, DECEMBER 12, 2011
beginning I kept having this nagging
thought: what is so bad about getting
better from a placebo?”
That kind of thinking, still hard for
most doctors to accept, was heretical in
1990, when Kaptchuk arrived at Harvard.
“People kept saying, ‘Oh, this is just
the placebo effect.’ You would hear that
every day,” Kaptchuk said. He had spent
years studying Chinese medicine (and
medical history), and this made no sense
to him. “I thought, Ted, step back a
minute. This wasn’t just something that
was a negative. It was something that
needed to be understood.”
Slowly, over the past decade, researchers
have begun to tease out the
strands of the placebo response. The
findings, while difficult to translate into
medicine, have been compelling. In most
cases, the larger the pill, the stronger the
placebo effect. Two pills are better than
one, and brand-name pills trump generics.
Capsules are generally more effective
than pills, and injections produce a more
pronounced effect than either. There is
even evidence to suggest that the color of
medicine influences the way one responds
to it: colored pills are more likely
to relieve pain than white pills; blue pills
help people sleep better than red pills;
and green capsules are the best bet when
it comes to anxiety medication.
Conditioning and expectations matter,
and so does learned behavior. In the
eighties, Levine and Gordon divided a
group of postoperative patients into three
sections: those in the first section received
morphine secretly, those in the
second were told they would receive
morphine (and did), and those in the
third were given a placebo that was described
as a powerful pain reliever. The
results were startling. Patients who were
told that they would receive a painkiller,
whether they actually received it or not,
had the same experience in the trial as
those who secretly received between six
and eight milligrams of morphine—a
significant amount. The covert dose had
to be increased to twelve milligrams to
surpass the effect of the placebo. Over
the past two decades, the Italian neuroscientist
Fabrizio Benedetti (who studied
with Gordon and Levine), and Luana
Colloca, a colleague of Benedetti’s, who
is now based in the United States, at
the National Institutes of Health, have
expanded on these studies. They have
found, for example, that diazepam—
more commonly known as Valium—has
no discernible effect on anxiety unless a
person knows he is taking it. And, increasingly,
studies like those have been
carried out with the help of imaging
techniques—such as PET scans and functional
M.R.I.s—that can track brain
changes as they happen. These advances
in brain imaging, along with an increased
understanding of neurochemicals, have
transformed a vague and mysterious notion
into a tangible effect that scientists
consider worthy of investigation.
“What’s exciting here is that, if we are
to talk about using placebos in a clinical
setting, they would have to have a measurable
effect and a biology we understand,”
Wayne Jonas told me. Jonas is an
interesting hybrid in a world often
sharply divided between conventional
and alternative therapies. In the early
nineties, he served as the director of the
Medical Research Fellowship Program
at the Walter Reed Army Institute of
Research, in Washington, D.C. He went
on to run the Office of Alternative Medicine
at the National Institutes of Health,
from 1995 to 1999. Today, Jonas is the
president of the Samueli Institute, a
Washington research group devoted to
shifting the focus of health care from
treatment to prevention.
“The morphine studies bring us a long
way,” he said. So did a recent investigation
by Kaptchuk, in which participants
“Bore me to sleep, Daddy.”
suffering from irritable-bowel syndrome
were not deceived about their treatment;
in fact, they were told in great detail about
the placebos they received and that they
were often as effective as real medicine.
The pills brought them relief.
For many people in the field, results
like those achieved in the morphine and
I.B.S. studies, while preliminary and in
need of confirmation, hint at something
far more significant than the effect of a
placebo or problems with a particular
drug. They suggest that the “magic bullet”
approach to health care—simple, effective
solutions to single problems, like a strep
infection or polio—can no longer remain
our principal approach to treating disease.
There has always been a distinction
between disease and illness. Disease is a
biological condition that we have historically
treated with drugs, surgery, and
other technological solutions. Illness, on
the other hand, defines the context of a
medical encounter, including the relationship
between doctor and patient.
Like Kaptchuk, Jonas believes that placebo
research demonstrates that it is essential
to consider both the science and
the art of medicine—to think about diseases
as illnesses, and not to rely solely on
short-term, high-tech solutions. Scientists
hope that, even if it proves impossible
to replace drugs with placebos, research
into the way they affect us will
accomplish nothing less than a transformation
of American medicine. “There are

“He’s the chief watchdog, who watches over all the other
watchdogs—but this must be his night off.”
no magic bullets for most of the problems
that ail us today,” Jonas said. “Diabetes,
immune-system disorders, chronic pain,
cancer. Our illnesses are complex, and we
need to approach them in more comprehensive
ways. We try to identify drugs
that will eliminate disease. Yet the way
we go about delivering those agents—the
interaction between doctor and patient,
for example—often has a bigger impact
than the agent we focus on. More than
the drug and more than the surgery. And
that has been collectively called the placebo
effect.”
The headquarters of the Food and
Drug Administration, situated on
a campus called White Oak, on the far
edge of Silver Spring, Maryland, seems
as close to the rest of the federal medical
establishment as it is to Pluto. There
is no Metro to White Oak, and it takes
half an hour to drive from the sprawling
campus to the National Institutes of
Health, in Bethesda. The F.D.A.’s
physical isolation belies its position as
the nation’s principal regulator of consumer
products. No drug is sold without
the agency’s approval. There will be
no prescriptions for any placebo, either,
unless clinical trials have demonstrated
its effectiveness to the satisfaction of
the F.D.A.
“One of the absolutely fundamental
problems that we have is the use of the
• •
term ‘placebo,’ which does nobody any
good,” Robert Temple told me, echoing
a complaint made by virtually everyone
who deals with the subject. Temple,
who has for many years run the F.D.A.’s
drug-evaluation department, is an owlish
man with a short, thick mustache and circular
glasses. His office is so filled with
towering stacks of files that, after you
enter, it takes a moment to find him. “Just
because something is called a ‘placebo
group,’ ” he said, “everyone assumes that
what happens in that group is a result of
the placebo effect. And that is absolutely
not true.”
Temple, who has worked at the
F.D.A. for four decades, rarely makes a
decision without angering somebody. He
has been regarded as a meddlesome reactionary
by H.I.V. activists and others
who insist that drugs be released more
rapidly. The more conservative medical
establishment frequently accuses the
agency of endorsing the wishful thinking
of drug manufacturers. And to the large
and growing community that supports
alternative approaches to medicine Temple
is Dr. No.
Temple said that he understands why
placebos attract people who become frustrated
when science fails to provide
definitive answers. “The persistence of
what people believe will save their lives as
opposed to the evidence is staggering,” he
said. “So people are talking about using
placebos as drugs. But I have no idea what
that means in practical terms. How would
it work?” Tantalizing hints and possible
effects are not data, and Temple says there
are no data that would suggest that placebos
are drugs. There are several studies,
though, that illustrate the basis for his
skepticism.
A placebo effect is commonly observed
during trials of blood-pressure
medications. To qualify for such studies,
subjects are supposed to have blood pressure
that exceeds a hundred and forty
over ninety in at least one of the two
measurements. “As soon as somebody
enters those studies, his or her blood
pressure falls an average of five or six millimetres
of mercury,” Temple said. “That
is significant, but it is not a placebo response,
and it is not a response to being
in the study. It is often the result of doctors’
inflating readings—of rounding up.”
If a person’s blood pressure is a hundred
and thirty-eight over eighty-eight, for example,
investigators will often include
him. “When you use an automatic bloodpressure
cuff to establish a baseline for
these kinds of studies, the entire placebo
effect vanishes,” Temple said.
When a drug (or a placebo) is under
study, subjects are usually divided into two
groups. Neither group knows exactly what
it is getting (nor do the doctors), but one
group generally receives the drug and the
other a placebo. “There is a better way,”
Temple said. “If you want to see if there is
a placebo effect, use three arms in a drug
trial, not two. Tell them, ‘Some of you will
be getting a drug, some will get a tablet
that looks like a drug but is nothing but a
sugar pill, and some of you will get nothing
at all.’
“It seems to me,” he went on, “that if
there is any substantial placebo effect,
there ought to be a difference between the
group that knows it’s getting nothing and
the group that doesn’t know it’s getting
nothing. If there is no difference, then
what are we talking about? Because it’s
not a placebo effect.”
It turns out that there have been many
trials of the type Temple mentioned. In
2001, the Danish epidemiologist AsbjØrn
Hróbjartsson, of Copenhagen’s
Nordic Cochrane Center, along with his
colleague Peter GØtzsche, published a
systematic review of a hundred and fourteen
clinical trials that compared patients
who received a placebo with subjects who
34 THE NEW YORKER, DECEMBER 12, 2011
were told that they would receive no
medicine at all. The researchers attempted
to assess the combined impact
of many different kinds of trials using
meta-analysis, a statistical technique for
extracting information from studies that
are not statistically significant by themselves.
Their article, “Is the Placebo Powerless?
An Analysis of Clinical Trials
Comparing Placebo with No Treatment,”
published in The New England
Journal of Medicine, was a long-overdue
response to Beecher’s 1955 paper.
In almost every case, the researchers reported,
there was essentially no difference
between the placebo group and the openly
untreated group. There were particular exceptions
in studies of pain, where there
was a slight but measurable placebo effect.
Since we are physiologically capable of
manufacturing our own painkillers—endorphins—the
result may not have been
surprising. Expectations and suggestion
clearly influence behavior, and when we
expect to receive medicine our bodies
often begin to prepare for it. (As the evolutionary
biologist Robert Trivers recently
pointed out, in “The Folly of Fools,” his
book about the historical necessity of deceit,
what the brain expects to happen in
the near future affects its physiological
state. Trivers’s theory would explain a fact
that has often baffled scientists: the placebo
effect doesn’t appear to work with
Alzheimer’s patients. Trivers suggests that
this is because most people who have Alzheimer’s
disease are unable to anticipate
the future and are therefore unable to prepare
for it.)
The Danish researchers repeated the
study in 2004, and again last year, incorporating
new data each time. The results
and their conclusions remained
the same. “We found little evidence in
general that placebos had powerful clinical
effects,” Hróbjartsson wrote. “Outside
the setting of clinical trials, there is
no justification for the use of placebos.”
Kaptchuk has great respect for Hróbjartsson,
yet he is wary of relying on
meta-analyses, and he believes that an
honest interaction between a doctor and
a patient can significantly alter the outcome
of treatment. That was the point of
his study of irritable-bowel syndrome, in
which some subjects were told that they
would not be treated. I.B.S., a chronic
gastrointestinal disorder, is one of the
most common reasons that people seek
medical care. Effective long-term therapies
have proved elusive. In Kaptchuk’s
study, eighty patients were randomly divided
into two groups. Patients in the first
group received a placebo pill twice a day;
those in the second received nothing. Before
the study began, both groups were
told that placebos were “inert or inactive
pills, like sugar pills, without any medication
in them.” They were also informed
that placebos have been shown in “rigorous
clinical testing to produce significant
mind-body self-healing processes.” Patients
who received the openly distributed
placebo scored far better on standard assessments
of their condition than those
who received nothing. There were also
statistically significant differences in the
severity of symptoms.
Although a group of eighty patients is
too small to draw definitive conclusions,
honesty seemed to work. “AsbjØrn’s stuff
is a constant intellectual challenge,” Kaptchuk
wrote in an e-mail. “His meta-analyses
are tops. Great methods, very careful.
Clear.” Yet Kaptchuk also pointed out
that placebos are not the only interventions
that can cause complicated reactions.
Drugs do, too. Opiods, for example,
increase pain in about ten per cent of
those who take them. Antibiotics don’t always
work, and neither does cortisone, a
powerful steroid used each year by millions
of people. Meta-analyses are useful
to help understand large amounts of data
from different trials. But statistical results
that combine information from a
variety of medical centers, with
different kinds of patients, often
in different countries, administered
under different conditions,
cannot be uniform and therefore
cannot be conclusive.
Hróbjartsson and Kaptchuk
are united on at least one front.
Like Wayne Jonas, they agree
that the medical system needs to
change. “You have to put this into
the context of the society in which
you live,” Hróbjartsson told me. “Because
I think this may be as much a matter of
philosophy as of science. There is an antitechnological,
anti-science feeling in the
West. We constantly see frustration with
the limits of medicine. The placebo can be
seen in some sense as a logical avenue for
those frustrations. Everyone wants a simple,
pain-free solution. But I wonder if that
approach isn’t just the mirror image of the
pharmacological way of handling illness—
that there is a pill for every disease.
“The entire idea of a placebo is very
‘soapy,’ ” Hróbjartsson continued. “It slips
away whenever you try to find a border.”
That has always been true. After all, for
many people a placebo is just a sugar pill.
For others, the definition includes the entire
ritual of treatment, the complete interaction
between doctor and patient. Increased
attention has mostly raised new
questions: What are the physical and psychological
mechanisms that produce placebo
effects? What are the conditions they
most easily affect? And can we actually
identify people who respond to placebos?
Scientists now have bits of answers to some
of those questions, but to reach their goal,
and introduce placebos into clinical practice,
they will need to answer all of them.
Ted Kaptchuk gets a great deal of
pleasure from focussing on what
other people reject. Indifference seems to
motivate him. “I was raised in a crazy
home, and it prepared me to accept any
proposition,” he said. That, he once told
me, is why he was so active in the sixties:
“It was a time when the underpinnings of
the universe were questioned.” Both of
Kaptchuk’s parents, who were Poles, survived
the Holocaust. “That really defines
a lot of what I do. My father was a Red,
so I have a tendency to get pleasure from
subversiveness.”
A particularly radical son of the sixties,
Kaptchuk was one of the
founders of the Columbia University
chapter of Students for
a Democratic Society, in 1965,
but the organization was soon
dominated by a faction that became
the Weather Underground.
That was too radical
even for Kaptchuk. He fled to
the West Coast. “I was hanging
out with the San Francisco Red
Guards and reading Mao, trying
to get away from U.S. imperialism,”
he said. “I was militant and crazy.
But at some point I said, Ted, this is not
being human.”
Kaptchuk decided to pursue studies in
Chinese philosophy and medicine at the
source. Beijing had yet to open its borders
to Americans, but Kaptchuk hoped
that his revolutionary bona fides would
prompt the leadership to make an exception.
“My request to study there was de-
THE NEW YORKER, DECEMBER 12, 2011 35
livered to the government by members of
the Black Panther Party,” he told me.
Even that didn’t work. The Chinese denied
the request, and Kaptchuk spent
much of the next decade studying in
Macau.
Today, it is hard to imagine Ted
Kaptchuk as a radical, let alone a fugitive.
He is an observant Jew who wears a yarmulke
on top of a shaggy bowl haircut
that looks as if he’d copied the Beatles,
circa 1964, then let it grow. As a devotee
of Eastern thought, he bars shoes from
his house and speaks in a hushed, measured
voice. David Carradine would have
played him beautifully.
Kaptchuk is the first prominent professor
at Harvard Medical School since
Erik Erikson with neither a medical degree
nor a doctorate, and it would be easy
to dismiss him as a signature representative
of the unsubstantiated-alternativehealth-care
movement. But he has published
scores of books, articles in highly
regarded peer-reviewed journals, letters,
and review notes—on subjects ranging
from placebo research to exorcism, from
cancer treatment to shaman rituals among
Navajo Indians. He has just finished a
study designed to answer a central question
in placebo research: Do the genes of
people who respond to placebos differ in
significant ways from those of people
who don’t? (The data, compelling but so
far preliminary, suggest that the answer
is yes.)
“Ted Kaptchuk is the most knowledgeable
person in the world on all matters
placebo,” Franklin Miller told me.
Miller is a senior faculty member in the
Department of Bioethics at the National
Institutes of Health. “He has done the
research, the scholarship, and the most
interesting and clinically relevant studies.”
One day, I asked Kaptchuk how a
man who practiced acupuncture and dispensed
herbs, rather than earning a
Ph.D. in biology or statistics, had learned
to design complicated trials. He told me
that he spent years seeking the advice of
the most highly respected and rigorous
medical statisticians. “I basically apprenticed
myself,” he said, “and they were
happy to help a quack who wanted to
deal with data.”
Kaptchuk is proud of being what he
calls “a card-carrying member of the
Harvard establishment.” It is a distinction
that did not come easily, even
though he has received millions of dollars
in funding for his projects from the
National Institutes of Health. “The goal
is to understand placebos so that they
may be used intelligently,” he said one
day. “But this is the area where I veer
from some of my colleagues. Because
what do I really want? Anything that
gets people away from the conveyor belts
that move from the pharmaceutical
houses to doctors and on to patients is
worth considering. Anything. We need
to stop pretending it’s all about molecular
biology. Serious illnesses are affected
by aesthetics, by art, and by the moral
questions that are negotiated between
practitioners and patients. Chiropractors
never say that your pain is all in your
head. But orthopedists do it all the time.
What a fucking way to try and help
somebody heal. Do you know how evil
that is?”
That kind of deeply held conviction
touches on the fundamental questions
that challenge American medicine.
Kaptchuk wants to broaden the definition
of healing, which is exactly what
enrages many scientists. In one recent
study of a major asthma drug, he and his
colleagues reported that, although placebos
had no impact on the chemical
markers that indicate whether a patient
is responding to therapy, patients nonetheless
reported feeling better. Kaptchuk
concluded that objective data should not
be the only criterion for doctors to consider.
“Even though objective physiological
measures are important,” he wrote in
the study, published earlier this year in
The New England Journal of Medicine,
“other outcomes such as emergency
room visits and quality-of-life metrics
may be more clinically relevant to patients
and physicians.”
“My jaw dropped when I read this,”
David Gorski, a professor of medicine at
Wayne State University School of Medicine,
wrote on the science blog Respectful
Insolence. “ ‘Other outcomes’
besides objective measures of disease severity
may be ‘more clinically relevant’?”
That kind of assertion clashes with the
basic truths of the scientific method.
Kaptchuk counters that we are losing
sight of our goal—which is to make
people feel better. “This study demonstrated
that, without a change in objective
data, you still get incredible subjective
improvement,” he said. “So is a
doctor really supposed to say, Gee, the
patient is feeling good but I better ignore
that and go by the numbers?”
It was late in the afternoon, and we
were sitting in Kaptchuk’s garden in
Cambridge. He looked at me and threw
his hands into the air. “Is my approach
just hocus-pocus?” he said softly. “Isn’t
that what you are really asking? You want
to know the relationship between rationality
and feeling and between science,
critical thinking, and the art of medicine.
And that boils down to one question: Do
you think this entire field is based on a
foundation of magical thinking, or do
you not?”
Three years ago, a week before
Thanksgiving, while I was sitting in
my office, my chest began to throb. It
was a diffuse pain, but pain nonetheless.
I am a middle-aged man with the usual
amount of stress (too much) and I handle
it in the usual way (denial). My cholesterol
and blood pressure are normal,
and I exercise regularly and try to eat sensibly.
Still, I have read many obituaries of
“healthy” men my age who ignored chest
pain. So, somewhat sheepishly, I called
my doctor and explained the situation,
and he told me to come right over.
He conducted a thorough examination,
and then we talked. He told me I
was fine, that Thanksgiving is often a
tense time, and that I should relax. My
pain suddenly disappeared. I have written
frequently of my belief that magic
is for fairy tales and science is for humans.
But something about that process
soothed me. Of course, it was a relief to
know that I wasn’t sick. But could words
really banish a pain I had struggled with
for hours?
After I got home, I realized that I had
been given a placebo. Not purposefully,
perhaps, but it had the same effect. My
doctor told me that I was fine, and that
made my pain go away. It also eased my
anxiety at least as effectively as if I had
swallowed a pill. My doctor takes an extremely
science-based approach to his
work. That’s what makes him so good at
his job. But that afternoon we engaged in
exactly the type of ritual that, according
to Kaptchuk, will have to play a critical
role in the future of American health
care. And, at least in this instance, it
would have been hard to argue that it
didn’t work. apple
36 THE NEW YORKER, DECEMBER 12, 2011