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were told that they would receive no medicine at all. The researchers at- tempted 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 them- selves. Their article, “Is the Placebo Pow- erless? An Analysis of Clinical Trials Comparing Placebo with No Treat- ment,” published in The New England Journal of Medicine, was a long-overdue response to Beecher’s 1955 paper. In almost every case, the researchers re- ported, there was essentially no difference between the placebo group and the openly untreated group. There were particular ex- ceptions in studies of pain, where there was a slight but measurable placebo effect. Since we are physiologically capable of manufacturing our own painkillers—en- dorphins—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 evo- lutionary biologist Robert Trivers recently pointed out, in “The Folly of Fools,” his book about the historical necessity of de- ceit, 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 pla- cebo effect doesn’t appear to work with Alzheimer’s patients. Trivers suggests that this is because most people who have Al- zheimer’s disease are unable to anticipate the future and are therefore unable to pre- pare for it.) The Danish researchers repeated the study in 2004, and again last year, incor- porating new data each time. The re- sults and their conclusions remained the same. “We found little evidence in general that placebos had powerful clin- ical effects,” Hrdbjartsson wrote. “Out- side the setting of clinical trials, there is no justification for the use of placebos.” Kaptchuk has great respect for Hré- bjartsson, 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 out- come 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 thera- pies have proved elusive. In Kaptchuk’s study, eighty patients were randomly di- vided into two groups. Patients in the first group received a placebo pill twice a day; those in the second received nothing. Be- fore the study began, both groups were told that placebos were “inert or inactive pills, like sugar pills, without any medica- tion in them.” They were also informed that placebos have been shown in “rigor- ous clinical testing to produce significant mind-body self-healing processes.” Pa- tients who received the openly distributed placebo scored far better on standard as- sessments 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. “Asbjorn’s stuff is a constant intellectual challenge,” Kapt- chuk wrote in an e-mail. “His meta-anal- yses are tops. Great methods, very careful. Clear.” Yet Kaptchuk also pointed out that placebos are not the only interven- tions that can cause complicated reac- tions. Drugs do, too. Opiods, for exam- ple, increase pain in about ten per cent of those who take them. Antibiotics don’t al- ways work, and neither does cortisone, a powerful steroid used each year by mil- lions 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, adminis- tered under different conditions, cannot be uniform and therefore cannot be conclusive. Hrébjartsson 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,” Hrébjartsson 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 sim- ple, 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, ” Hrébjartsson 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 en- tire ritual of treatment, the complete inter- action between doctor and patient. In- creased attention has mostly raised new questions: What are the physical and psy- chological mechanisms that produce pla- cebo 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 prac- tice, they will need to answer all of them. T: 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: “Tt was a time when the underpinnings of the universe were questioned.” Both of Kaptchuk’s parents, who were Poles, sur- vived 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 six- ties, Kaptchuk was one of the founders of the Columbia Uni- versity chapter of Students for a Democratic Society, in 1965, but the organization was soon dominated by a faction that be- came the Weather Under- ground. 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. imperial- ism,” 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 bor- ders to Americans, but Kaptchuk hoped that his revolutionary bona fides would prompt the leadership to make an excep- tion. “My request to study there was de- THE NEW YORKER, DECEMBER 12, 201 35 HOUSE_OVERSIGHT_029930