Georg Ivanovas From Autism to Humanism - systems theory in medicine
2. The medical paradigm
“I believe the real lesson physicians can learn from the placebo experience is not that an inactive compound may be therapeutic but rather that the body’s healing responses may be activated by the patient’s anticipation of a cure. The challenge lies in learning what we have to do as healers to most effectively activate these mechanisms” (Melmed 2001b).
Whereas the discussion on psychosomatic confusion suffers from an undisciplined thinking, the usual approach in the assessment of effectiveness of a therapy goes the other way. It follows a very clear and strict pattern. The attempt to establish knowledge with placebo controlled trials is a straightforward method. May be, this is why it is liked so much. A minute analysis, however, shows that this method also suffers from a kind of undisciplined thinking. This lack of discipline has, again, to do with its epistemology. The placebo-phenomenon is discussed in detail, as it demonstrates some kind of unavoidable confusion when health and therapy are described with unsuitable tools. As soon as a systemic concept is used all the paradoxes around the placebo effect vanish.
Placebos are the centre of every medical trial, they are the foundation of ‘evidence based medicine’. There exists even an institute to investigate their effects (UCLA Neuropsychiatric Institute) and “more placebos have been administered to research participants than any single experimental drug. Thus, one would expect sufficient data to have accumulated for the acquisition of substantial knowledge of the parameters of placebo effects “ (Kirsch/Sapirstein 2001). But the opposite is true. Only those who never looked closely at the issue know what it is. Indeed, there seems to be nothing more enigmatic than the placebo effect (Roth 2003).
In short, the placebo effect is an ‘anomaly of normal medicine’. Anomalies of normal science are, as Kuhn stated, no anomalies but processes that cannot be described properly with the current paradigm. This is has been stated by many scientists: “The placebo effect is… all that is beyond scientific explanation in the healing process” (Grob, P, cited in Gauler/Weihrauch 1997: 42, my translation). “Placebos are the ghosts that haunt our house of biomedical objectivity, the creatures that rise up from the dark and expose the paradoxes and fissures in our self-created definitions of the real and active factors of treatment” (Harrington 1997: 1). It also has been called the ‘nuisance variable’ just to spoil the whole subject (Peek/Coleman cited in Spiro 1997: 40).
Therefore, the uncertainty around the placebo effect is not due to a lack of knowledge or data, but due to a lack of a suitable epistemological tool. As long as certain inadequate axioms are maintained, the placebo effect will continue to create difficulties.
Although everybody concerned with placebo effects is well aware of the paradoxes, in every day discourse there is a naïve realism (often with an twinkle of the eye) knowing exactly what placebo means and by that it resembles a bit the notion of mind. However, „the biggest enemy of understanding the placebo is common sense” (Field 1997: 216).
The main explanation of the placebo effect is that it is a ‘psychological’ or ‘psychosomatic’ process. But, as shown before, this is but a word if it does not refer to a mechanism of action. It is not only poor reasoning, it does not stand up to all research as well. A higher suggestibility, e.g., does not correspond with a higher susceptibility to placebos. Also most other attempts to model the ‘psycho’-hypothesis scientifically failed (Gauler/Weihrauch 1997: 14-16).
In this chapter I will show that
- the placebo effect is an explanatory principle,
- the placebo effect is a statistical parameter,
- the placebo effect is an expression of an arbitrary causalisation,
- the placebo effect vanishes if a systemic view is taken.