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were told that they would receive no medicine at all. The researchers attempted to assess the combined impact of many different kinds of trials using meta-analysis, a statistical technique for extracting information from studies that are not statistically significant by themselves. Their article, “Is the Placebo Powerless? An Analysis of Clinical Trials Comparing Placebo with No Treatment,” published in The New England Journal of Medicine, was a long-overdue response to Beecher’s 1955 paper.

In almost every case, the researchers reported, there was essentially no difference between the placebo group and the openly untreated group. There were particular exceptions in studies of pain, where there was a slight but measurable placebo effect. Since we are physiologically capable of manufacturing our own painkillers—endorphins—the result may not have been surprising. Expectations and suggestion clearly influence behavior, and when we expect to receive medicine our bodies often begin to prepare for it. (As the evolutionary biologist Robert Trivers recently pointed out, in “The Folly of Fools,” his book about the historical necessity of deceit, what the brain expects to happen in the near future affects its physiological state. Trivers’s theory would explain a fact that has often baffled scientists: the placebo effect doesn’t appear to work with Alzheimer’s patients. Trivers suggests that this is because most people who have Alzheimer’s disease are unable to anticipate the future and are therefore unable to prepare for it.)

The Danish researchers repeated the study in 2004, and again last year, incorporating new data each time. The results and their conclusions remained the same. “We found little evidence in general that placebos had powerful clinical effects,” Hróbjartsson wrote. “Outside the setting of clinical trials, there is no justification for the use of placebos.”

Kaptchuk has great respect for Hróbjartsson, yet he is wary of relying on meta-analyses, and he believes that an honest interaction between a doctor and a patient can significantly alter the outcome of treatment. That was the point of his study of irritable-bowel syndrome, in which some subjects were told that they would not be treated. I.B.S., a chronic gastrointestinal disorder, is one of the most common reasons that people seek medical care. Effective long-term therapies have proved elusive. In Kaptchuk’s study, eighty patients were randomly divided into two groups. Patients in the first group received a placebo pill twice a day; those in the second received nothing. Before the study began, both groups were told that placebos were “inert or inactive pills, like sugar pills, without any medication in them.” They were also informed that placebos have been shown in “rigorous clinical testing to produce significant mind-body self-healing processes.” Patients who received the openly distributed placebo scored far better on standard assessments of their condition than those who received nothing. There were also statistically significant differences in the severity of symptoms.

Although a group of eighty patients is too small to draw definitive conclusions, honesty seemed to work. “Asbjørn’s stuff is a constant intellectual challenge,” Kaptchuk wrote in an e-mail. “His meta-analyses are tops. Great methods, very careful. Clear.” Yet Kaptchuk also pointed out that placebos are not the only interventions that can cause complicated reactions. Drugs do, too. Opioids, for example, increase pain in about ten per cent of those who take them. Antibiotics don’t always work, and neither does cortisone, a powerful steroid used each year by millions of people. Meta-analyses are useful to help understand large amounts of data from different trials. But statistical results that combine information from a variety of medical centers, with different kinds of patients, often in different countries, administered under different conditions, cannot be uniform and therefore cannot be conclusive.

Hróbjartsson and Kaptchuk are united on at least one front. Like Wayne Jonas, they agree that the medical system needs to change. “You have to put this into the context of the society in which you live,” Hróbjartsson told me. “Because I think this may be as much a matter of philosophy as of science. There is an anti-technological, anti-science feeling in the West. We constantly see frustration with the limits of medicine. The placebo can be seen in some sense as a logical avenue for those frustrations. Everyone wants a simple, pain-free solution. But I wonder if that approach isn’t just the mirror image of the pharmacological way of handling illness—that there is a pill for every disease.

“The entire idea of a placebo is very ‘soapy,’” Hróbjartsson continued. “It slips away whenever you try to find a border.”

That has always been true. After all, for many people a placebo is just a sugar pill. For others, the definition includes the entire ritual of treatment, the complete interaction between doctor and patient. Increased attention has mostly raised new questions: What are the physical and psychological mechanisms that produce placebo effects? What are the conditions they most easily affect? And can we actually identify people who respond to placebos? Scientists now have bits of answers to some of those questions, but to reach their goal, and introduce placebos into clinical practice, they will need to answer all of them.

Ted Kaptchuk gets a great deal of pleasure from focussing on what other people reject. Indifference seems to motivate him. “I was raised in a crazy home, and it prepared me to accept any proposition,” he said. That, he once told me, is why he was so active in the sixties: “It was a time when the underpinnings of the universe were questioned.” Both of Kaptchuk’s parents, who were Poles, survived the Holocaust. “That really defines a lot of what I do. My father was a Red, so I have a tendency to get pleasure from subversiveness.”

A particularly radical son of the sixties, Kaptchuk was one of the founders of the Columbia University chapter of Students for a Democratic Society, in 1965, but the organization was soon dominated by a faction that became the Weather Underground. That was too radical even for Kaptchuk. He fled to the West Coast. “I was hanging out with the San Francisco Red Guards and reading Mao, trying to get away from U.S. imperialism,” he said. “I was militant and crazy. But at some point I said, Ted, this is not being human.”

Kaptchuk decided to pursue studies in Chinese philosophy and medicine at the source. Beijing had yet to open its borders to Americans, but Kaptchuk hoped that his revolutionary bona fides would prompt the leadership to make an exception. “My request to study there was de-

THE NEW YORKER, DECEMBER 12, 2011 35

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