This column is adapted from The Voodoo That You Do: The Placebo Effect in Mediation, presented at the International Institute for the Sociology of Law in Onati, Spain on July 9, 2010.
Suppose we have four people. Let’s call them Groucho, Harpo, Chico, and Zeppo. Groucho has a broken arm and goes to a physician. Harpo has lower back pain and goes to a Therapeutic Touch practitioner. Chico and Zeppo have a lawsuit, and they go to a mediator. Let’s follow them and see what happens.
Groucho’s doctor starts by examining Groucho’s arm. She does a history and physical. She takes x-rays. She reviews his records to see if there are any pre-existing medical conditions that might affect his treatment. Based on what she learns, she determines a course of action.
Groucho’s doctor will set and cast his arm according to well understood and universally applied procedures. Any doctor competent to treat broken arms will treat Groucho the same way any other competent physician would.
After six weeks Groucho’s cast will be removed and his arm will have healed. This is so whether Groucho believes in Western medicine or not. It is so even if Groucho has been in a coma since his accident.
Harpo takes his back pain to an alternative medicine practitioner. I chose Therapeutic Touch for this example because it is among the most thoroughly discredited forms of alternative medicine. By holding their hands a few inches above a patient’s skin, Therapeutic Touch practitioners claim to be able to perceive irregularities in the invisible energy field surrounding injured or diseased body parts. By moving their hands they claim to be able to adjust those energy fields and restore health to the affected areas. In a justly famous experiment performed by an 11-year-old girl, Therapeutic Touch practitioners were asked to place their hands through holes in a piece of cardboard. With their view of the experimenter’s hands blocked, the practitioners were found not only to be unable to determine whether a presented hand had a disturbed energy field, but unable to determine whether there was a hand present at all.
But Harpo doesn’t know this. He has heard good things about Therapeutic Touch in general and this practitioner in particular. His back pain is particularly acute and he has gotten no relief from his usual treatment. He very much hopes therapeutic touch will work, and from what he has heard he expects that it will.
The practitioner gives Harpo a line of mumbo-jumbo and goes through some hocus-pocus. She talks about the polarity of his energy field. She says she can sense a disturbance in his aura. Whatever. She says he should feel better in a couple of days.
In fact, Harpo feels better almost immediately. Why?
Part of the reason Harpo feels better has to do with the natural history of back pain. It comes and goes. Part has to do with regression to the mean. A particularly bad day of back pain is likely to be followed by a day that is not so bad. This is not because of anything the patient may have done or refrained from doing. It is simply because a particularly bad day of back pain is an extraordinary event, and extraordinary events are rare.
Part of the answer has to do with conditioning. We feel better after a visit to the doctor because we have come to associate doctor visits with improved health. Part of the answer has to do with stress. Illness is associated with fear. To the degree that fear can be reduced, the body’s natural defenses can more effectively combat illness. When we expect to feel pain relief, the body releases endogenous opioids and pain relief is experienced. It doesn’t matter whether the expectation is medically justified or not. Patients given medically inert substances experience pain relief as long as they believe they are getting pain reliever.
We know that Therapeutic Touch has no medical value. It is medically inert, like a sugar pill. But we also know that it makes people feel better. Not everyone. Not people who think it is quackery, not people in comas, but, for people who believe it will work and who expect it to work, Therapeutic Touch makes them feel better. This is the placebo effect.
There is no question that real, measurable medical improvement often accompanies placebo therapy. There is more work to be done before a full understanding of placebo effects can be achieved, but the basic outline of the process is fairly well understood.
Chico and Zeppo
Chico and Zeppo take their lawsuit to a mediator. The question I want to ask is this: Is their experience with their mediator more like Groucho’s with his doctor or more like Harpo’s with his quack?
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