Over the last few years, Gunnar Tjomlid has rightly built up a reputation as the best skeptical blogger in Norway. Consistently insightful, even-handed, almost obscenely thorough, and perhaps most importantly, accessible, Saksynt is a fantastic example of grassroots skepticism. His award at the Vixen Blog Awards a couple of weeks ago was richly deserved, and came in the same week that he was embroiled in a controversy that had other bloggers accusing him, amongst other things, of trivializing child pornography for daring to turn a skeptical eye to sensitive issue.
Placebodefekten, released by Humanist Forlag in the Autumn of last year, draws together ideas, criticisms and explanations from Tjomlid’s countless blog posts over the last few years to discuss some of some of the psychological, biological and societal factors that come together to produce the placebo effect – a phenomenon much more complex than just something that ‘works’, or has an effect, because you expect it to – and how, in combination with a raft of shortcomings in the way we see the world, it contributes to the popularity and proliferation of alternative therapies.
By definition, alternative therapies are those that have either not been proved to work, or been proved not to work. Despite this, they continue to remain popular and proliferate, with millions of spent on chiropractic, acupuncture, homeopathy, reiki and the like, every year.
Testing whether something ‘works’ is not just a matter of measuring if someone gets better after being treated. The treatment effect (the measure of whether the treatment works) is a combination of the genuine therapeutic effect of the treatment, the natural development of the disease or illness, and the placebo effect in addition. The natural progression of the ailment and the placebo effect are commonly and wrongly conflated. Tjomlid does a fantastic job of untangling them and explaining how and why therapies which have no scientific basis or evidence-base behind them appear to help people get better.
No one’s going to die from a swallowing a homeopathic sugar pill or dangling a crystal over their head but alternative therapies don’t stop there. Whilst chirocpractic can occasionally have deadly consequences, it’s the anti-vaccine movement we have most to worry about. Not vaccinating yourself or, worse (because I think it is a dereliction parental duty) choosing not to vaccinate your child, isn’t just a matter of personal choice and freedom: compromising herd immunity is having devastating and deadly consequences.
One of Tjomlid’s analogies, when deconstructing the idea that vaccines are bad because they’re ‘unnatural’ and ‘what doesn’t kill you makes you stronger’ bears repeating. If a wolf was attacking a child, no parent would hesitate in fighting the wolf off, despite it being within the wolf’s nature to attack the child. But when we get smaller in scale, down to bacteria and viruses, the same thinking doesn’t seem to apply. Whilst the principle of protecting a child from harm is the same in each case, using vaccines to protect against nature’s microscopic predators is seen as wrong because instead of say a throwing a rock or a stick or firing a gun we are now using denatured proteins. In trying to ‘protect’ children, the anti-vaccine movement, driven by fears of ‘chemicals’ and/or the now thoroughly debunked idea that vaccines cause autism and/or in extreme cases government mind control devices, are doing the exact opposite.
Much of Placebodefekten covers familiar ground for skeptics: our natural tendencies for pattern-seeking, poor memory and memory reconstruction, confirmation bias, our drive to seek cause and effect relationships, and for order and control in our lives. That’s not to say that the seasoned skeptic won’t learn something new; I picked up countless ways to better explain these biases to others and there were plenty of ‘oh, I hadn’t thought about it like that before’ moments. (Case in point: I’ve been using the terms ‘alt-med’ or ‘alternative treatments’ since forever but will now exclusively use ‘alternative therapies’ as both the former terms imply a level of underserved legitimacy.)
Each chapter ends with an ‘alternative cliché’ (‘it worked for me!’, ‘it’s ‘natural’ so it must be safe and good for you’, ‘it strengthens your immune system’, ‘the placebo effect doesn’t work on children and animals’ etc.) which is pithily dismantled in a couple of hundred words. They’re a useful reference point next time you have a friend or relative extolling the virtues of alternative therapies but not the time or perhaps ability to explain the intricacies of human psychology and the immune system.
It’s the personal ‘it worked for me’ or 'my son was vaccinated and was then diagnosed with autism' stories that are powerful and stick in the memory – anecdotes are one of the strongest weapons in the armoury of alternative therapy practitioners and advocates. ‘The plural of anecdotes is not data!’ is the skeptic’s cry, and whilst this is true, it has resulted in skeptics shying away from utilizing the power of narratives and –wrongly – thinking that numbers and facts will do all the work.
One of the real strengths of Placebodefekten is way Tjomlid uses anecdotes as a way to frame the science. Personal stories, such as his quest to get to the bottom of a frequently upset stomach, walk the reader through just how easy it is to convince yourself, even as a skeptic, of the wrong thing. Short stories of Stein Alderman (stone-age man; a clever pun in Norwegian) going about his daily business break up the pace and set up some of the chapters with entertaining analogies of cognitive biases. These stories give meaning to the skepticial thinking behind them, and have greater effect than just playing ‘name that logical fallacy’ and shouting ‘post hoc ergo propter hoc!’ , which I’ve often seen skeptics do.
The final chapter, which focuses on the wider social and implications of the placebo effect, is when things get really interesting. How can/should those practicing science-based medicine use the placebo effect in an effective and ethical way is a tricky question, not least because the answer must take into account the ethical implications of doctors potentially lying to patients, withholding the truth or talking up the effect of a treatment, whilst in no way legitimizing the use of alternative therapy placebos like homeopathy.
Tjomlid suggests that one thing health practitioners can learn from alternative therapists, and a good way to potentially utilize the placebo effect whilst avoiding many tricky ethical issues, is to give the patient time, listen attentively, take them seriously and make them feel valued. This sounds sensible enough but there are two significant problems. The first is very practical: health services are already over-stretched and most doctors just do not have the time for lengthy consultations. The second strikes at the heart of an important conundrum set out in the final chapter of Placebodefekten. Tjomlid, quite rightly, identifies our increasingly medicalized lifestyles as one of the root causes for the continuing popularity of alternative therapies in the face of overwhelming evidence against their efficacy. As a result of the ever-decreasing risk of disease and illness (thanks in no small part to conventional medicine and vaccines of course), small, generalized complaints (tiredness, lack of sleep, irritability etc.) become more noticeable and significant to the individual – these are exactly the kinds of ailments that can’t be easily ‘treated’ and are exactly the kinds of diffuse, fluctuating and self-correcting things homeopathy and the like claim to cure. In advocating for doctors to use more time listening to the patient, and perhaps performing a (non-invasive) medical examination that is not strictly necessary in order to utilize the placebo effect, there is a very real danger of legitimizing non-serious complaints and creating a vicious cycle of medicalization, which keeps the door to alternative therapies open.
Thought-provoking, entertaining and informative, Placebodefekten is an effective vaccine against uncritical thinking. I suggest getting immunized as soon as possible and reading Saksynt for regular booster shots.
In in terms of my 52-books challenge this is a bit of a cheat as I finished reading the book over Christmas. I’d half written the review then, with the idea that it might go in the next issue of Argument, but I’ve decided to cut back on a few things so it’s just going up here. Book 3, AC Grayling’s Liberty in the Age of Terror, will now be book 4. I’ve already started on book 5, Erik Tunstad’s Juks, but that might be replaced by the new released Religionskritikk by Gunn hild Lem, which was released on Wednesday.