The pervasive placebo effect

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Snake Oil Science: The Truth about Complementary and Alternative Medicine. By R. Barker Bausell. Oxford University Press. New York, 2007. ISBN 978-0-19-53168-0. 324 pp. Hardcover, $24.95.

An ad in a recent edition of the Charlotte Observer newspaper was headlined "Treating Mind, Body and Spirit." It touted a medical facility staffed by an MD who is a fellow in integrative medicine, an RN, and a "LAc, MSTOM" who is a diplomate of Oriental medicine. According to the ad, the facility blends "cutting-edge internal medicine with ancient and complementary therapies to deliver evidence-based holistic treatment. ... Complementary therapies include meditation and massage, reiki and quantum touch, acupuncture, and much more."

In the November/December 2007 SKEPTICAL INQUIRER, Edzard Ernst introduced us to The Prince of Wale's Foundation for Integrated Health, a U.K. lobby group promoting "complementary healthcare." And, says Ernst, the foundation has powerful support, including that of the U.K. Department of Health.

Under pressure, primarily from Iowa Senator Tom Harkin, the U.S. National Institutes of Health (NIH) established an Office of Alternative Medicine, which became the National Center for Complementary and Alternative Medicine. The center started funding high-quality, well designed clinical trials of complementary and alternative medicine (hereafter CAM) therapies. Bausell was the research director of an NIH-funded CAM specialized research center, where he was in charge of conducting and analyzing randomized clinical trials of acupuncture's effectiveness for pain relief.

The establishment of the National Center for CAM is an interesting development in light of the CAM community's discouragement of internal dissent based on the belief that the community was besieged from the outside and "that the validity of their therapies transcends conventional scientific methods altogether" (xii). This, says Bausell, is a contemporary version of the age-old phenomenon of the collision between science and belief.

The fundamental question Bausell addresses is whether or not CAM therapies work. The key to answering the question is the phenomenon of the placebo effect, which he considers "at least as interesting and counterintuitive as any New Age health practice" (xv). This book, says Bausell, is the first scientific evaluation of CAM. Most research on CAM has been poorly designed and executed. And poorly conducted research almost always produces false positive results, that is, that the CAM therapy under investigation is effective when in fact it is not.

But just what is CAM? It is the set of practices that continues to be used in the absence of both scientific evidence that supports the practices' efficacy and a plausible biological explanation for why they should be effective. Even worse, these practices continue to be used even after there is persuasive evidence that they are ineffective and their supposed biological basis is discredited. CAM practitioners do not value--and most, in his experience, says Bausell, do not understand--the scientific process.

Snake Oil Science is devoted primarily to the placebo effect. A placebo is a pharmacologically or physiologically inactive substance or procedure that can have a therapeutic effect if administered to a person who believes that he or she is receiving an effective treatment. To assess the efficacy of medical procedures and treatments, research must be designed to control for positive results that may be due wholly or in part to a placebo effect. The best type of research design involves random assignment of patients to a group that will experience the treatment under investigation, other patients to one or more groups that receive the placebo therapy, and another group that receives neither the treatment nor placebo. The best design also involves "double blinding," meaning neither the researchers nor the patients know which group any given patient is in.

According to Bausell, the most obvious problem involved in integrating research on CAM is that so much of that research appears to totally disregard or to be totally ignorant of the best

research practices and designs. "This abysmal lack of research quality" (Bausell 115) makes interpreting the results of any systematic review of CAM research extremely difficult.

Bausell devotes a chapter to each of the following topics: Impediments to Making Valid Causal Inferences; Impediments Preventing Physicians and Therapists from Making Valid Inferences; Impediments Preventing Poorly Trained Scientists from Making Valid Inferences. He illustrates the points primarily with fictional accounts of doctors treating patients' chronic pain with acupuncture, but CAM studies concerned with other health problems (e.g., high cholesterol, depression) and treatments are also cited. Another chapter is devoted to Judging the Credibility and Plausibility of Scientific Evidence. The goal is to determine if there is a CAM therapeutic effect over and above what can be attributed to a placebo effect--and if there is a CAM therapeutic effect, is there is a plausible biochemical mechanism that could explain it?