by Ian Leslie
By the time the Royal Commission was formed, Mesmer had given up his search for official approval, and he refused to cooperate with it. He knew that the Establishment cronies gathered in Franklin’s garden would label him a fraud: that was what their instincts for self-preservation compelled them to do. As far as he was concerned, what mattered was that his methods worked. Hundreds of satisfied patients would testify to that. ‘It is to the public I appeal,’ he said, cannily framing the contest as one between the honest masses and a corrupt elite. The commissioners, serious men, weren’t asking whether Mesmerism worked, however, but why. When Mesmer’s patients collapsed on to his thick-pile carpets, what were they falling for?
In deference to Franklin’s age (seventy-eight) and his physical discomfort with travelling (he had a painful kidney stone), much of the commission’s work was carried out at Passy. In Mesmer’s place, Doctor Charles Deslon agreed to act as the advocate for Mesmerism. Deslon, a former court physician, was the only convert to Mesmerism from the medical establishment, and had been expelled from the faculty of medicine for his heresy. He was eager to prove that Mesmerism was legitimate; Mesmer denounced and disowned his former disciple for his cooperation.
After spending a few weeks listening to Deslon lecture on the theory of Mesmerism, the commissioners underwent mesmerising themselves, to little effect (Franklin reported only boredom). They then embarked on a series of elegant experiments. In one, they told a female subject falsely that she was being mesmerised by Deslon, behind a door in the next room. This was enough to send her into a violent crisis. Another woman, previously very responsive to mesmeric treatment, was blindfolded and ministered to by Deslon without her knowledge, yet reported no effects at all. Five cups of water were held before another of Deslon’s patients; the fourth produced convulsions, yet she calmly swallowed the fifth, the only one to have been mesmerised. Then there was the experiment with which we opened this story. Deslon ‘magnetised’ an apricot tree in Franklin’s garden by passing his wand across it. Deslon was then invited to choose the subject of the test – he deemed the sickly boy especially sensitive to animal magnetism. The boy went into a crisis before reaching the magnetised tree. With these experiments the commissioners had designed the first application of placebo-controlled blind testing in the history of modern medical science.
The commission’s report, published in September 1784, is a masterpiece of the clear thinking for which Franklin and his colleagues were renowned. It carefully explains how the investigation looked for evidence of the existence of Mesmer’s magnetic fluid but found none. The effects were real – there was no suggestion that the sickly boy or any of the other subjects were faking their crises or their recoveries – but it was necessary to look elsewhere for causes:
Thus forced to give up on our search for physical proof, we had to investigate mental circumstances, operating now no longer as physicists but as philosophers . . . Whereas magnetism appears nonexistent to us, we were struck by the power of two of our most astonishing faculties: imitation and imagination. Here are the seeds of a new science, that of the influence of the spiritual over the physical.
Mesmerism remained popular in France for a few years more, though after his humiliation by the Establishment Mesmer himself left Paris for England and Italy, hoping for a new start that never came. He died in relative obscurity in 1815, by the shores of Lake Constance in Germany, not far from where he was born. The chimes of an armonica sang him to his rest. Deslon died in August 1786, while being mesmerised.
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The authors of the Mesmerism report found that the cures by animal magnetism were in fact produced by social and mental causes (‘imitation and imagination’). Crucially, they were careful not to dismiss such effects as irrelevant or unworthy of study. The ‘new science’ they proposed implied something like a fusion of what today we call social sciences – psychology, anthropology, sociology – with biological medicine.
For two centuries, the medical profession failed to cultivate the seeds sown by Franklin and Lavoisier. In its struggle to distance itself from superstition, magic and quackery, it built a wall between science and everything intangible. As a result, the ‘influence of the spiritual over the physical’ became something of a taboo question, regarded by physicians and researchers alike as beneath or behind them. Doctors saw themselves as scientists of the physical world whose object of study happened to be the human body, a machine of nature that operated according to reliable laws. (This is also, of course, how Mesmer saw things.) As the medical historian David Morris puts it, if you conceive of the body as a machine, then believing in the power of lies to erase pain is ‘as irrational as filling the gas tank of a car with tea’.
Only in recent years has it begun to be accepted that sickness and health aren’t just biological affairs. ‘Imitation’ is increasingly viewed as playing a significant role in the health of individuals and populations. Mesmer’s treatment worked more powerfully when his patient was surrounded by other patients sharing the same experience, and there’s now plenty of evidence to show that our behaviours and health are strongly influenced by those around us, including large-scale studies that track the spread of conditions like heart disease and obesity through social networks.
Our own health is bound up with our relationships to other people, particularly those who seek to cure us. Much depends on the signals the physician sends, consciously or unconsciously, about his confidence in the treatment; in the phrase of the medical anthropologist Daniel Moerman, the physician’s demeanour seems to ‘activate the medication’. Medical researchers who carried out a historical review of the literature on the treatment of angina found that drugs that worked in the 1940s and 1950s dramatically decreased in effectiveness in the 1960s. This change was hard to explain in biochemical terms: the drugs hadn’t changed, and nor had the human body. The authors of the study concluded that it hinged on the rise of the double-blind trial, which revealed to the medical profession that some of the drugs they had been using worked no better than placebos. In other words, patients who received the medication from doctors who truly believed that it was powerful were much more likely to get better than those who received it from doctors who had their doubts.24
It’s not just the doctor himself who affects our confidence or inspires our imaginations, it’s everything that surrounds him; the cultural symbols of health and healing. The psychologist Irving Kirsch enrolled students on the pretext of trialling a new anaesthetic cream to which he gave the impressive-sounding name of Trivaricane. The students were shown the bottle. On the label were the words approved for research purposes only. The experimenter – introduced as a ‘behavioural medicine researcher’ – wore a white coat and snapped on a pair of surgical gloves, explaining that she wanted to be sure she wasn’t over-exposed to the Trivaricane. After administering the sham cream and giving it a minute or two to ‘work’, a mechanical gadget was used to apply a sharp force to the student’s fingers, one finger at a time. The students were asked to rate the pain on each finger and reported feeling much less pain on the finger that had been ‘treated’. A British study of headache pills showed that an unbranded, real pill worked better than an unbranded sham pill, but worse than a placebo pill that came in the packaging of a famous brand of headache remedies. The real branded pill worked best of all.
When a person receives a genuine medical treatment and makes a recovery, three things are going on at once. First, the surgical procedure, or the physiologically active pharmaceuticals of the drug, act on the body. Second, the body’s superb self-healing system gets to work, its actions enhanced by the patient’s expectations of recovery, which are catalysed by the treatment. Third, the patient’s belief in the person treating them, or the symbols associated with the treatment, affect their expectations and thus their physiological state. The term placebo effect is used to cover the last two, which of course can take place without the first, but it might be better named the ‘beli
ef effect’ – after all, a placebo pill does nothing, by definition. Placebo is just a word for the healing that happens because somebody believes that the treatment they’ve received will make them better. If you don’t believe in a lie, it won’t make you better.
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Franklin’s scepticism about Mesmerism was evident in a letter he sent, shortly before joining the commission, in reply to a sick man who had asked him whether, in his opinion, it would be worthwhile taking a trip to Paris to see Dr Mesmer. Typically of Franklin, it is written in plain language but is dense with insight:
There being so many disorders which cure themselves and such a disposition in mankind to deceive themselves and one another on these occasions . . . one cannot but fear that the expectation of great advantage from the new method of treating diseases will prove a delusion.
That delusion may, however, in some cases, be of use while it lasts. There are in every great city a number of persons who are never in health, because they are fond of medications, and by always taking them, hurt their constitutions. If these people can be persuaded to forbear their drugs in expectation of being cured by only the physician’s finger or an iron rod pointing at them, they may possibly find good effects tho’ they mistake the cause.
Franklin hints here at the usefulness of medical lies – they help people feel better without creating dependence on potentially damaging physical treatments. But is it ever acceptable to deceive patients? Many doctors persuade themselves that it is. According to Anne Helm of the Oregon Health Sciences University, between thirty-five and forty-five per cent of all medical prescriptions are placebos. A 2003 study of eight hundred Danish clinicians found that almost half prescribed a placebo at least ten times a year. These aren’t ‘pure’ placebos; doctors prescribe medications with small active elements in them, though not something that’s going to act on the ailment in question.
Although it’s commonplace, placebo-prescribing is a controversial practice within the medical community. After all, the healing power of doctors, and indeed, the very possibility of placebo effects, relies in part on the trust that patients place in them. As the philosopher Sisella Bok puts it, ‘to permit a widespread practice of deception . . . is to set the stage for abuses and growing mistrust.’ Other parties to the process are forced to become accomplices to the deception; an article in the Journal of the American Pharmaceutical Association provides a script for the pharmacist faced with a prescription that is clearly a placebo: ‘Generally, a larger dose is used for most patients, but your doctor believes that you’ll benefit from this dose.’
Of course, doctors aren’t deceiving for the sake of it; they are usually doing so for the good of their patients, and anyway, identifying what does or doesn’t constitute deception in this context is not straightforward. If a doctor prescribes a pill to a patient, knowing that the pill itself will have no effect on their condition but hoping that the act of administering it will encourage the patient’s recovery, is he deceiving? He’s certainly not being entirely honest. If he were, he would say something like, ‘The pill I’m giving you has no active ingredient that will cure your symptoms, but all you really need is something to believe in, and this will do.’ But if he said this, he would quite obviously be undermining the very effect that might lead to the patient feeling better. On the other hand, he doesn’t have to engage in outright deception either. Walter Brown, professor of clinical psychiatry at Brown University, suggests that sometimes doctors should be able to tell patients that although the pill they are dispensing contains no active drug, ‘Many people with your condition have found that it helps.’
What definitely would constitute deception is if the doctor invented a false ‘scientific’ story to explain how the treatment works. This is what upsets scientists about the alternative medicine industry, which seems to borrow, deceitfully, from the language of biomedical science to enhance its own authority. The homeopathic establishment, with its talk of molecule clustering and nanobubbles, dresses up its treatments in the language of pharmacology. What sceptics find infuriating about homeopathy is that it manages to have it both ways, presenting itself as an alternative to traditional medicine while at the same time relying on its vocabulary for a specious authority.
Homeopathic treatments can work, however, even if most evidence suggests they work purely through the belief effect, and from the therapeutic experience of an encounter with a sympathetic practitioner. Given this, even the sceptic might argue it would be wasteful and destructive to ban them from our pharmacy shelves, or indeed from the NHS. Indeed, it might be dangerous for conventional doctors to shun alternative cures entirely. If some patients see conventional medicine and ‘complementary’ medicine as a competition between science and caring (or between technology and tradition), then they may refuse conventional treatments that offer their only hope of a cure.
Rather than defending their turf, perhaps evidence-based physicians ought to focus their efforts on expanding it. Already, doctors increasingly accept that the wider, intangible aspects of well-being are important; that a physician who stares at his computer screen while you tell him about your symptoms is less likely to cure his patient than one who looks like he cares; that the best way for a person to stay healthy in old age is to stay socially active – and that these are scientific truths as much as folk wisdoms. But there is a long way to go before our doctors become ‘scientists of the spirit’ as well as the body.
Scientifically grounded medicine is a vastly welcome but very late development in the human story. For most of our history we’ve been blundering from one mistaken idea about how the body works to another. Metaphor, ritual and symbol were all we had for combating disease, whether we knew it or not.25 If people responded positively to the touch of the shaman, the apothecary’s elixir, or even harmful treatments like bloodletting – and one of the reasons such treatments persisted is that they often did work – it was at least partly because they believed in them, or in the physician dispensing them.
Lavoisier and Franklin were avid readers of Montaigne, and their report was influenced by an essay of his entitled ‘The Power of the Imagination’ (1574), in which he argued that medicine was based on deceit. Physicians, said Montaigne, exploit the credulity of their patients with ‘false promises’ and ‘fraudulent concoctions’; if their cures work it is mainly because of the patient’s lively imagination. He described a woman who was convinced that she had swallowed a pin in a piece of bread and was ill as a result. Her doctors didn’t believe her but had no success in relieving her symptoms, until one day they gave her an emetic and secretly placed a needle in her vomit. She was cured. (The metaphor of exorcism or excision, in which something malign – a spirit, a tumour, a gallstone – is removed from the body by the healer, is one of the most enduring and powerful tropes of medicine. A 2009 study found that patients undergoing surgery to correct painful spinal tears reported greater improvement when, after the operation, they were shown fragments of the removed disc.)
Although nobody quite knows why it is that beliefs – regardless of whether they’re true – are so central to our physical well-being, the behavioural scientist Dylan Evans has proposed an intriguing explanation. Noting that we are the only animal to practise medicine (chimps take care of each other when injured, but primatologists have never observed one chimp giving medical assistance to another), he suggests that it began as a way of stimulating positive beliefs about recovery:
By the time the human lineage began to diverge from that of the chimpanzees, some five million years ago, the capacity for immune conditioning was well established. At some point our ancestors discovered they could activate it deliberately. They found quite by chance that they could train their immune systems to respond to certain stimuli in ways that felt quite beneficial. These stimuli – dabbing leaves on each other’s wounds, perhaps, or giving each other special herbs when sick – were the origins of medicine.
Early humans who had acc
ess to the power of the belief effect – activated through culture – would have secured an advantage over those who did not. In other words, the very survival and reproduction of our species has relied on our ability to deceive ourselves and others into thinking that we are going to get better even when there is no objective reason why we should. Small wonder, then, that lies continue to exert such a far-reaching effect on our health and happiness.
Lies We Live By: Part Two
The power of stories to shape our lives
We tell ourselves stories in order to live.
Joan Didion
In 2002, the research director of the pharmaceuticals giant Merck announced that his company’s aim was ‘to dominate the central nervous system’. According to Steve Silberman of Wired magazine, the key to this grandiose ambition was the development of a powerful new anti-depressant, codenamed MK-869, which would enable Merck to take on competitors like Pfizer and GlaxoSmithKline who had created some of the best-selling and most famous anti-depressants. In early tests, MK-869 had performed brilliantly: those taking it reported pronounced and lasting improvements in their sense of well-being. But when it was tested against a placebo pill MK-869 suddenly looked less impressive. The volunteers in the group taking the placebo felt much happier too, and to a degree comparable to those who had taken the real thing. In trial after trial, Merck couldn’t prove that MK-869 worked better than a sugar pill. In the evocative phrase used by the industry to describe a drug that fails in testing, MK-869 crossed ‘the futility boundary’, and was abandoned.
