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beginning I kept having this nagging thought: what is so bad about getting better from a placebo?”
That kind of thinking, still hard for most doctors to accept, was heretical in 1990, when Kaptchuk arrived at Harvard. “People kept saying, ‘Oh, this is just the placebo effect.’ You would hear that every day,” Kaptchuk said. He had spent years studying Chinese medicine (and medical history), and this made no sense to him. “I thought, Ted, step back a minute. This wasn’t just something that was a negative. It was something that needed to be understood.”
Slowly, over the past decade, researchers have begun to tease out the strands of the placebo response. The findings, while difficult to translate into medicine, have been compelling. In most cases, the larger the pill, the stronger the placebo effect. Two pills are better than one, and brand-name pills trump generics. Capsules are generally more effective than pills, and injections produce a more pronounced effect than either. There is even evidence to suggest that the color of medicine influences the way one responds to it: colored pills are more likely to relieve pain than white pills; blue pills help people sleep better than red pills; and green capsules are the best bet when it comes to anxiety medication.
Conditioning and expectations matter, and so does learned behavior. In the eighties, Levine and Gordon divided a group of postoperative patients into three sections: those in the first section received morphine secretly, those in the second were told they would receive morphine (and did), and those in the third were given a placebo that was described as a powerful pain reliever. The results were startling. Patients who were told that they would receive a painkiller, whether they actually received it or not, had the same experience in the trial as those who secretly received between six and eight milligrams of morphine—a significant amount. The covert dose had to be increased to twelve milligrams to surpass the effect of the placebo. Over the past two decades, the Italian neuroscientist Fabrizio Benedetti (who studied with Gordon and Levine), and Luana Colloca, a colleague of Benedetti’s, who is now based in the United States, at the National Institutes of Health, have expanded on these studies. They have found, for example, that diazepam—more commonly known as Valium—has no discernible effect on anxiety unless a person knows he is taking it. And, increasingly, studies like those have been carried out with the help of imaging techniques—such as PET scans and functional M.R.I.s—that can track brain changes as they happen. These advances in brain imaging, along with an increased understanding of neurochemicals, have transformed a vague and mysterious notion into a tangible effect that scientists consider worthy of investigation.
“What’s exciting here is that, if we are to talk about using placebos in a clinical setting, they would have to have a measurable effect and a biology we understand,” Wayne Jonas told me. Jonas is an interesting hybrid in a world often sharply divided between conventional and alternative therapies. In the early nineties, he served as the director of the Medical Research Fellowship Program at the Walter Reed Army Institute of Research, in Washington, D.C. He went on to run the Office of Alternative Medicine at the National Institutes of Health, from 1995 to 1999. Today, Jonas is the president of the Samueli Institute, a Washington research group devoted to shifting the focus of health care from treatment to prevention.
“The morphine studies bring us a long way,” he said. So did a recent investigation by Kaptchuk, in which participants suffering from irritable-bowel syndrome were not deceived about their treatment; in fact, they were told in great detail about the placebos they received and that they were often as effective as real medicine. The pills brought them relief.
For many people in the field, results like those achieved in the morphine and I.B.S. studies, while preliminary and in need of confirmation, hint at something far more significant than the effect of a placebo or problems with a particular drug. They suggest that the “magic bullet” approach to health care—simple, effective solutions to single problems, like a strep infection or polio—can no longer remain our principal approach to treating disease.
There has always been a distinction between disease and illness. Disease is a biological condition that we have historically treated with drugs, surgery, and other technological solutions. Illness, on the other hand, defines the context of a medical encounter, including the relationship between doctor and patient. Like Kaptchuk, Jonas believes that placebo research demonstrates that it is essential to consider both the science and the art of medicine—to think about diseases as illnesses, and not to rely solely on short-term, high-tech solutions. Scientists hope that, even if it proves impossible to replace drugs with placebos, research into the way they affect us will accomplish nothing less than a transformation of American medicine. “There are

[Cartoon image of a man reading to a child in bed]
“Bore me to sleep, Daddy.”

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