In her book The Magic Feather Effect, journalist Melanie Warner covers placebo research, shows that alternative medicine is placebo medicine, takes a “try it yourself” approach, and gives belief and anecdotes more credit than they deserve.
In the movie Dumbo, a little elephant with large ears can fly by flapping them like wings, but he refuses to believe he can. A mouse uses a psychological trick to persuade him, telling him that holding a “magic feather” will enable him to fly. He gives Dumbo an ordinary crow feather and Dumbo uses it to fly in a circus act. When he accidentally drops the feather, the mouse tells him it wasn’t magic but only worked as a confidence-builder, and Dumbo continues to fly without it.
A new book, The Magic Feather Effect: The Science of Alternative Medicine and the Surprising Power of Belief, by the journalist Melanie Warner, sees Dumbo’s feather as an analogy for alternative medicine. The analogy is imperfect, but the idea is that alternative medicine providers persuade patients to accept a non-reality-based belief, and believing has a powerful placebo effect that allows the mind to heal the body. Unlike Dumbo’s feather, a patient who improves with alternative medicine is never told the treatment was imaginary. There is no “science of alternative medicine”. If it were based on science, it would not be “alternative”, but would simply be part of medicine. Alternative medicine is placebo medicine. Science has not shown it to be “powerful” in the accepted sense. She portrays it as powerful based largely on anecdotal evidence of seemingly miraculous healings.
One-sided anecdotal reporting
Her reporting is one-sided. She emphasizes failed back surgeries and other failures of medicine, and she interviews people who believe alternative medicine has cured them; but she doesn’t make any attempt to balance their accounts with interviews of people who alternative medicine harmed or failed to help. She doesn’t even mention the What’s the Harm website, which collects reports of people who were harmed or died because they put their trust in the fantasies of alternative medicine.
She devotes several pages to a seemingly miraculous recovery from quadriplegia attributed to unconventional treatments.
She visits a patient who was allegedly cured of pheochromocytoma at Lourdes, and learns that the diagnosis may have been incorrect. She hypothesizes that the patient’s symptoms may have been psychological distress that triggered physical symptoms, claiming that relief of psychological distress counts as a miracle cure. A doctor tells her “Our belief in miracles has a fantastic placebo effect.” She does not reveal that out of 200 million patients who have visited Lourdes, only 67 were validated by the Catholic church as having experienced a “medically inexplicable” cure; and most of those actually were medically explicable as conditions that were susceptible to psychosomatic influences or known to show spontaneous remissions. Not so fantastic. Those statistics are a powerful argument against her “magic feather” thesis.
She questions the concept that treatments should be proven more effective than placebo in randomized, blinded, placebo-controlled trials. For her, it is enough for patients to report feeling better. “Effective” is subjective, anecdotal, not objectively measurable improvement. She assumes placebos work and jumps the gun to investigate how they work.
Good reporting of placebo research
Her investigation of the scientific research on placebos is the best part of the book. She cites many studies and the criticisms of the studies. She explains the role of conditioning and suggestion.
The brain can produce its own pain-killing chemicals. Experiments have shown that the opioid antagonist naloxone reverses the pain-killing effect of placebos. In Parkinson’s disease, the brain released dopamine when told a saline injection was a Parkinson’s drug. Patients believe that surgery will be effective, and in several studies fake surgeries have worked just as well as real surgeries.
Kaptchuk’s acupuncture research has shown that interactions with warm, empathetic providers got better results than impersonal, perfunctory interactions; and patients on a no-acupuncture waiting list got far worse results.
Warner’s reporting of the research does suffer one flaw: her unquestioning acceptance of useless studies that compare alternative treatments to a waiting list and studies that add an alternative treatment to the usual care. She seems not to realize that such studies are a waste, because the outcome can be predicted. They will always show that the alternative treatment “works”, because doing anything new is always better than doing nothing. As Edzard Ernst has shown, these trial designs cannot generate a negative result.
Fabrizio Benedetti is a meticulous and prolific placebo researcher. She attends his lectures and interviews him. He is trying to understand the biological basis of placebo responses, but he doesn’t think his laboratory studies have practical clinical applications. Placebo responses are short-lived, and they can produce nocebo effects. He stresses that they are only effective for certain subjective symptoms, that there is a difference between care and cure, and that there are serious ethical concerns.
Warner also interviews Benedetti’s protégé Luana Colloca, who endorses the “better than usual care” criterion for effectiveness rather than “better than placebo”. She believes her allergic asthma was cured by a single acupuncture treatment. When she told Benedetti, his interpretation was that she was a very good placebo responder.
She covers chronic pain, the research into how it develops, and the fact that altering mindsets is a major goal of pain clinics. She tells an anecdote about a patient who was resistant to all treatments until a clairvoyant told her there was nothing wrong with her back. This was a “shock to her mind”, a kind of miracle that enabled her brain to eliminate the perception of pain overnight.
She covers research on stress, meditation, inflammation, biophotons, hallucinations, synesthesia, and Tai Chi. Tai Chi was thought to influence the immune system and have other benefits. But a study showed otherwise. It compared tai chi to cognitive behavioral therapy (CBT) for patients with rheumatoid arthritis. CBT had a modest effect on pain, inflammation, and immune markers; but in the Tai Chi group there was nothing – not even a reduction in pain. The study was never published “because the lead author didn’t know how to explain the results.” That’s irresponsible: science advances by studying unexplained results.
The value of alternative medicine
The value of alternative medicine lies in the lengthy encounters with providers who make patients feel supported and listened to, who give them confident explanations (usually false) of exactly what is wrong, and who confidently promise to fix the problem.
She interviews a “healer” who seems to have the whole package of everything placebo researchers say makes for an effective therapeutic encounter: meaningful attention, expression of empathy, listening skills, earnest eye contact, steady projection of confidence, and an office adorned with a suggestive assembly of symbols.
On a visit to a Psychosomatic Medicine clinic in Germany, she finds that patients are seldom “cured” but they develop a sense of control, empowerment, improved self-esteem, and more self-confidence.
If alternative medicine lies are able to evoke a placebo response that produces healing, exposing the truth should allow the healing to continue just as the mouse’s revelation to Dumbo allowed him to keep flying. But that’s not the way it works. Placebos are not powerful, and the myths that alternative medicine practitioners feed patients are more acceptable to them than a truth that will require them to reject strongly held beliefs. Desperate patients seek out confident, empathetic practitioners, even if the treatments they offer are based on total nonsense.
Unfair criticism of skeptics
She criticizes skeptics for having too little interest in the mind’s role in health and healing. I think skeptics are very interested in the mind’s role, but they are not credulous: they insist on good evidence. One book reviewer said, “For all the value the skeptics provide in finding objective truth, sometimes in their need for academic certainty they lose sight of what matters to their patients.” The reviewer goes on to ask, “But in the end, if your life is measurably better, does it matter?” Yes, it matters! And skeptics have explained why (ethics, failure to get lifesaving treatment, undermining critical thinking, etc.) I am convinced that truth matters. For my column in Skeptical Inquirer, I chose the title “Reality Is the Best Medicine.” The Journal of the American Medical Association used to have a series with facing pages: on the left, a patient declared his cancer cured by an unconventional treatment, and on the right they posted his death certificate showing that he died of that cancer shortly after his testimonial.
She singles out Steven Novella and David Gorski for discouraging further acupuncture research; but she doesn’t fully explain their reasoning, which I think is eminently valid.
Try it for yourself
She tries everything for herself, experiencing energy medicine, acupuncture, bathing at Lourdes, even letting a chiropractor pop her neck despite understanding that there is a small risk of complications such as stroke and death. Personal experimentation may be persuasive journalism, but it is not good science. If she improves, she can’t know if it was because of the treatment; and if she doesn’t improve, that is not evidence that it is ineffective for others. Controlled scientific studies are the only valid way to determine the truth.
She tried craniosacral therapy and despite knowing that the bones of the skull don’t move, she is “taken aback that the right side of my head does seem decidedly higher.” She didn’t try to find any objective evidence. Her subjective impression was enough for her.
With regard to energy medicine, she reveals her bias by saying, “I yearned to have a reason to believe…The possibility of phenomena that science has failed to detect has a tantalizing thrill. Throughout history, many ideas have been unreasonable and preposterous until they weren’t… In the absence of hard evidence, it seems what I may need to have is a personal encounter with the anomalous force so many others say they have experienced.” She took classes but was unable to learn to see auras or have the experiences others had.
In the first chapter she undergoes muscle testing (applied kinesiology) before and after an intervention by an energy medicine practitioner. She experiences unexplained arm weakness and is impressed, but in a later chapter she reports a simple explanation: a chiropractor who used to be an enthusiastic muscle tester eventually realized he was unconsciously pushing in a different way when he expected the patient to be strong, appearing to use the same force but actually using less force than when he wanted their arm to give way.
Illness vs. disease; what does “healing” mean?
She points out that illness and disease are not the same thing. Disease is objective pathology; illness is the lived experience of the patient.
Autonomic systems like the immune system and the neuroendocrine system can be modified by learning and conditioning. Pain perception and other symptoms are conscious events that can be modulated by expectations and patient-doctor communication.
She says peace and acceptance can be its own kind of profound healing.
She says, “I try not to harden around my skepticism.” This strikes me as an admission that she rejects scientific rigor in favor of gee-whiz anecdotal evidence. There is nothing hardened about skepticism. It is not dogma or systematic disbelief; it is a process that evaluates claims and only accepts beliefs that are based on good evidence: the essence of what good scientists do.
She protests that she will always side with science and couldn’t possibly defend the flood of nonsense, but she insists she has seen alternative medicine therapies help people and the stories they weave provide meaning and comfort. She says that until more doctors learn to offer the things alternative medicine offers, to evoke the power of belief and hope, and to treat the patient rather than the disease, alternative medicine isn’t going away.
Conclusion: Lessons to be learned
Warner makes the case that alternative medicine offers something of value to some patients, although it involves persuading the patient to believe in fantasies like acupuncture points, undetectable energies, chiropractic subluxations, and other magic feathers. As Mark Crislip said, “While changing the perception of disease for the better is of benefit, it is just not ethical to base treatment on a lie.” What if understanding the science behind the placebo/contextual effect of the provider/patient encounter could enable them to provide the value without the deception? I question whether that is possible for alternative medicine, which relies so heavily on confident explanations that have no basis in reality.
But I think it is an achievable goal for science-based providers. Clinical medicine is not just science; it’s applied science. Its goal is:
To cure sometimes, to relieve often, to comfort always.
It’s easy to get fixated on scientific trials and lose sight of the need to comfort the patient. Surely we can do better. I wouldn’t call it “healing”, but comforting another human being is important too.
This article was originally published in the Science-Based Medicine Blog.
