From Placebo to Homeopathy: The Fear of the Irrational

Today's biomedical science oscillates between rigorous approaches, with rational attitudes, and irrationality or incoherence. Thus, in the era of molecular biology, psychoanalysis thrives and represents a multimillion-dollar annual business, whereas other such "nonmaterialistic" disciplines as homeopathy, acupuncture, or hypnosis are a priori and uncritically rejected by hard science. Indeed, the temptation is to reject anything without a molecular explanation--better to deny a fact than get mixed up with a fluke. But if reason has partially freed us from medieval beliefs, it is now proving to be self-destructive (F. Schiller, Clinical Medicine, 19:81-6, 1984). For when facts are rejected as unreasonable in the name of reason, we are adopting the same superstitious approach to reality as people did in the Middle Ages. The placebo effect is a perfect illustration of scientific exorcism of a disturbing fact (W.A. Brown, Scientific American, Jan. 1998, pages 68-73). Although its existence has been established beyond doubt, all efforts are directed not toward studying its mechanisms, but to subtracting its interference. To satisfy statisticians and referees, constraints have become more stringent and ethics are bent--as are coherence and logic--so that one is justified in wondering whether randomized clinical trials, necessary for producing placebo-free data, are not "the worst kind of epidemiology," deliberately ignoring the individual patient's welfare in the name of science (B.G. Charlton, Nature Medicine, 1:1101-2, 1995). For when a physician knows that treatments are not equivalent, ethics require that the superior treatment be recommended. Only when equipoise is reached--a state of genuine uncertainty regarding the comparative therapeutic merits--can randomized clinical trials be acceptable. If, for a number of patients, an inert substance with nil toxicity produces the same beneficial results as a toxic pharmaceutical compound, logic would require that the phenomenon be thoroughly investigated for the patients' benefit, and for its potential to reduce medical costs. However, because of the implicit psychological mechanisms underlying the effect, placebo has maintained and reinforced its dubious reputation, thus impeding further research. Hence, the real placebo paradox, which illustrates the schizophrenic paranoia of today's medicine: since placebo equates in the minds of many to a psychosomatic, i.e., unreal illness, administering it is synonymous with medical deception and unscientific maneuvering, even if the patient's pathology improves. Modern medical logic would rather that treatments were inefficacious than incomprehensible. And yet, for economic, ethical, and purely scientific reasons (especially in an era when certain effects of the immaterial soul can be pinned down to a secretory activity of the brain), the placebo effect warrants further investigation, as does homeopathy, a controversial practice plagued by the same type of ostracism. In France, for instance, where homeopathic drugs are used by one-third of the population and paid for by national health insurance, their cost represents only 1 percent of that of conventional drugs. Whether observed clinical improvements are illusory or due to placebo effect, the results satisfy the vast majority of patients and physicians who use these compounds, even if it is shocking for well-thinking scientists to accept that high dilutions of chemicals can display activity, as the homeopathy theory claims. In an era when over-medication threatens the basis of health policies, the rationale for encouraging the fashion for innocuous, low-cost, and yet effective medicines is evident. Nonetheless, it would be more intellectually satisfying and morally acceptable to know whether a homeopathic prescription is handed out because of its placebo power or its direct effect on the biochemistry of the organism. Nobody seems to be interested in exploiting homeopathy as a placebo tool, or in funding bona fide research that should prove (or disprove) the underlying theory. Here, again, the attitudes of the proponents and opponents of the hypothesis evoke religious wars, irrationality, and intellectual dishonesty. Yet, several clinical studies suggest genuine effects (K. Linde et al., Lancet, 350:824-5, 1997). But the debate being a passionate one, it will probably never come to a head, every side determined to debunk and ridicule the opponent's position before even considering the evidence. Interestingly, the a priori rejection of "impossible" facts does not only concern fringe disciplines and nonmaterialistic phenomena. It can also strike at once-respectable hard data. One of today's most salient examples is that of transfer factor, an immunomodulator long lauded for producing extraordinary clinical results within the realm of cell-mediated immunity (D. Viza, Biotherapy, 9:17-26, 1996). In the 1990s, it became a non-grata research topic, because its molecular structure could not be elucidated. Forty years' research, which has generated more than 1,000 clinical and laboratory reports, seems to have been wasted because we are still determined to ignore writer George Santayana's warning: "Those who forget the past are destined always to repeat it." At the turn of the century, one can but hope that scientists will one day cease to compete with priests and politicians in their race for certainty, and accept at last, as philosopher Karl Popper contends, that, unlike psychoanalysts, their fate is always to be wrong. Scientific arrogance might then subside, making science healthier, and also--most important for some--more productive. Dimitri Viza is director of the Immunobiology Laboratory at the Faculte de Medecine des Saints-Peres in Paris. E-mail: viza@citi2.fr

From Placebo to Homeopathy: The Fear of the Irrational

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