Doctors, Patients and Placebos by Howard M. Spiro MD (Yale University:$27.50; 261 pp.)
United States medical care has been bombarded by criticism in recent years because of its soaring costs, high-technology, access barriers and inequities, and above all for its impersonality.
Popular dissatisfaction with these and other ills has never gainsaid the superb advances in biomedical research--in genetics, immunology and bioengineering--often swiftly translated into new therapies that improve the life of patients.
But deep and nagging questions persist. How can doctors become more understanding of the total context in which human beings get sick, react to, and fight to overcome their illnesses? How can professionals and our whole health-care “system” become more responsive and helpful in the lives of patients, especially those with chronic illnesses, the major health threats of our time?
Thirty years ago, social scientists began to teach in medical schools, hoping that their special knowledge and viewpoints, integrated into the enormous subject matter that medical students must absorb, would mitigate some of these popular criticisms. They weren’t conspicuously successful. When I was one of them, I felt like a missionary preaching to a primitive tribe--sometimes you converted an exceptional native or two, but more often, we proselytizers were ignored or laughed at.
The successful clinicians and brilliant researchers in the “hard” biomedical sciences became the role models for future physicians; simultaneously, the social idealism of beginning medical students was transmuted to individualistic, career concerns. The dynamic advances in biomedical knowledge and technology, and a free-market delivery “system” far outweighed in influence the “soft” social sciences, and their closest medical ally, psychiatry.
But recent years have seen a promising countertrend to broaden medical education and practice from their concentration on curing specific diseases and malfunctions, to considering the “whole” patient in diagnosis and treatment. This requires attention to the social-psychological context of the patient’s life-family relationships, work, social situation and environment. A sizable literature has appeared that bases the need for this revised orientation not merely on humanistic or philosophic grounds, but on demonstrated clinical knowledge and research.
Howard M. Spiro’s book is one of the most complete and best of these recent efforts to broaden current medical thinking and practice. An experienced clinician, and a longtime teacher of gastroenterology at the Yale Medical School, he addresses primarily medical students and colleagues in this book, but it is so well presented and non-technically written that many lay people will find it accessible and fascinating reading.
Spiro analyzes in detail the placebo’s uses in clinical medicine. Most of us know that a placebo is an innocuous substance that does not attack the patient’s physical problem; a phony pill or injection believed to be a powerful antibiotic is a classic example. Spiro shows that from ancient times, placebos have been much used by physicians and other healers. Prior to the widespread use of the sulfa drugs and penicillin, many of the medications doctors used were placebos. They were often surprisingly effective--so much so that when a new drug is tested, it must be shown to be more effective than a placebo.
Spiro thoroughly analyzes reports of the effectiveness of placebos in many disorders. They show consensus that about one-third of patients benefit psychologically from their use. He believes that fundamental disease processes are not altered, only the patient’s perceptions; but placebo relief of pain and other suffering are so real that they should not be dismissed by physicians but studied further.
After analyzing many historical, psychological and legal aspects of placebo use, Spiro turns to some key issues in medical philosophy and care: limitations of the orthodox, scientific model of medicine; differences between “disease” and “illness” (the patient’s perceptions), the doctor’s need to listen to patients, “the power of community” or social support to reinforce desired patient behaviors.
Analysis of these complicated issues leads Spiro into other excursions: a capsule history of medicine, from classical times to the present; anthropological studies of healing in non-Western and premodern societies and their use of placebo-analogues; the methodologies of scientific investigation, possibilities for change in medical education. Although not new, each of these excursions is well done, and they reveal Spiro as a cultivated humanist, a well-read social philosopher, as well as a sensitive clinician.
This reviewer has some reservations, however. In discussing the varied grab-bag of concepts and therapies known as “holistic” medicine, Spiro is critical of unfounded claims, anecdotal evidence and quackery dangers. But he does not recognize that the appeal of these approaches arises from popular resistance to conventional, high-tech and high-priced medicine, nor does he credit enough their contributions in influencing and changing the orthodox approaches. He dismisses the validity of Norman Cousins’ accounts of his illnesses and undervalues Cousins’ influence on both the public and on physicians.
Although “the power of community” is one of his stated themes and interests, Spiro scarcely discusses the subject, except to refer slightingly to a grass-roots consumer group, the rapidly growing Peoples Medical Society. The dynamic role in health education and self-care of the many health-oriented self-help groups is not touched on.
Yet through the “power of community,” these organizations provide essential social support for many people--of a kind not available from MDs and other health professionals.
These lay resources need to be understood by physicans and other health workers and incorporated into established healing and health delivery systems. Spiro’s blinkered vision regarding them probably stems from his pride in the accomplishments of his profession, his position and contributions to it. But he and other dedicated healers should more fully understand that the promotion and maintenance of health, the treatment and prevention of disease, are not the exclusive domain of professionals, but require the involvement of the whole society, of patients and potential patients in particular.
