Soothsaying: Placebo and Those-(not)-Supposed-to-Know
A talk given at the Institute of Psychoanalysis, London, 10th December 2025 [pdf]
Etymolude
To soothe, from Old English gesóðian, to calm, tranquillise, is the same word as ‘sooth’, truth, from Old English soð, true. Though the truths offered by soothsayers are not always, or even usually, soothing, the words sooth and soothe suggest a movement in the same direction as placebo, which came to designate a flatterer, offering soothing, but untrustworthy words. Martius, in Shakespeare’s Coriolanus, assumes the affinity of the two words in saying ‘when drums and trumpets shall/I’ th’ field prove flatterers, let courts and cities be/Made all of false-fac’d soothing’ (Shakespeare 2011, 222), and Coriolanus will deploy the same quibble later in his words to Brutus declining to have his martial exploits praised: ‘When blows have made me stay, I fled from words./You sooth’d not, therefore hurt not’ (Shakespeare 2011, 227). Helicanus seems to assume a similar association when he warns Pericles ‘When Signior Sooth here does proclaim a peace,/He flatters you, makes war upon your life’ (Shakespeare 2011, 983).
But what is it to soothe? What is soothing about the truth, if the truth is that one is unwell? Do people want to be well, that is, unaware of what is wrong with them? And what is the truth about soothing? Is there sooth in soothing saying? Self-soothing, the capacity of babies, in many of its own marvel made, and in some, I among them, preserved no less wondrously into slumberous age, to fall asleep on their own, was described by Thomas F. Anders in 1979, a phenomenon that has come to be known as ‘self-soothing’, though Anders himself does not use the phrase. But ‘self-soothing’ has been in use since at least the late seventeenth century, the earliest citation in the OED being the advice in John Dickenson’s Historie of Faire Valeria (1598) that
tempestes in the prime of Autumne, are least dreaded, but most dangerous. Shame sinnes guerdon, is then nearest, when through selfe-soothing securitie, the feare thereof is fardest (Dickenson 1598, 32)
Closer to us the usage very likely helps tune Wallace Stevens’s crooning lines:
It is a child that sings itself to sleep,
The mind, among the creatures that it makes,
The people, those by which it lives and does. (Stevens 1984, 436)
S’il Vous Plaît
One of the most singular, and still mysterious forms of implicit belief is that which operates in the phenomenon of placebo. The power of what is called the ‘placebo effect’ is the power of belief made active, or affect made effectual. The power of placebo is very substantial.
Typically patients in trials of medicine are divided, unknown to themselves or to the experimenters (the ‘double-blind’ condition) into a group who receive a given a medication and a group who are given instead a placebo, meaning a neutral substance, that, since it cannot be expected to have any effect, can act as a baseline against which the biochemical effects of the medicine can be measured.
The difficulty with this kind of procedure is that it has been known for at least 250 years as a well-articulated principle, and probably for very much longer as an implicit form of intuition or expectation, that placebo medicines given under certain circumstances can have very powerful effects, almost always positive, and often mimicking the effects that are expected or hoped for. Indeed, given the tenuous biochemical basis of most forms of medicine or therapeutic procedure before around the middle of the nineteenth century, it would be reasonable to assume that almost all the benefits of medical care in the thousands of years that preceded bacteriological and other forms of understanding of the physical processes of disease and cure relied heavily upon the operations of placebo. This is not a new insight, though as one might expect it is more commonly articulated during the period in which medicine became able to claim scientific status, roughly from Pasteur onwards. W.R. Houston declares emphatically in 1938 that, in the past, ‘the medicines used were placebos, something to please the patient. The doctor, himself, by words of cheer and comfort sought to please the patient. His medicines were merely symbols to reinforce this purpose’ (Houston 1938, 1417).
There continue to be many disagreements about the nature and workings of placebo, amounting even to what, with dreary inevitability, have been called ‘placebo wars’ (Foot and Ridge 2012). Discussions of placebo have abounded since the second half of the twentieth century, and always, whether explicitly or implicitly, seem to bear on questions of the dignity, authority and responsibility of medical care. In arguing against the idea of placebo, or assuming that the placebo effect is something to be ruled out in experimental investigations of drugs or procedures, many writers seem to be defending against the charlatanism or dumb luck of the medical past the reliability and respectability of the physiological model of disease and treatment that has predominated for two centuries. For others, the placebo effect is a complimentary testimony to the power of medical knowledge and the authority of its institutional representatives. My interest in placebo is animated by the specific question of the role in it of the implicit – implicit knowledge, implicit faith, things assumed to be known, and things we seem to know how to do without knowing, or at least being able to tell each other, quite how. The idea of placebo marks a stubbornly ineradicable fault-line between the aim of modern medicine to draw more and more of the workings of the body out into explicit understanding and an experience of the body as, for most times and places in human history, a terra incognita, and indeed the embodiment of the implicit itself, intimately known, but only mistily understood.
The word placebo has a curious history. It is the first word of St Jerome’s translation of Psalm 116.9: ‘placebo Domino in regione vivorum’: ‘I will please the Lord in the land of the living’. Placebo is in fact a mistranslation of אֶ֭תְהַלֵּךְ, which means ‘I will walk’. Though this account of the origin of the word placebo has often been rehearsed, I have not so far come across any explanation of why Jerome might have been led into this particular mistake, even assuming that he was working from a reliable Hebrew original. The psalm alternates rejoicing at the mercy and bounty of the Lord, and affirmation of faith that the Lord will respond in a similar way in the future: dilexi quoniam exaudiet Dominus vocem orationis meae quia inclinavit aurem suam mihi et in diebus meis invocabo: I have loved, because the Lord will hear the voice of my prayer. Because he hath inclined his ear unto me: and in my days I will call upon him. Pleading and pleasing are both at work in the psalm, which alternates between praise for the blessings which the Lord has given in the past and confident expectation that this will continue after death. It is a kind of prayer, in which a statement of faith does the work of an optative: would that, may it be that, let it be that.
One might say that prayer itself operates in the manner of a medical placebo: its manifest form is a petition to an external agent, but latently it seems to invest faith in the power of prayer itself, to which the act of prayer seems itself to be directed. In order to be effective, prayer seems to take its own efficacy ‘for granted’, in a performative exercise of wishing magic (Connor 2023b, 134-5) and perhaps something of the same logic is at work in the gratifying or rewarding effect of placebo. Prayer is a kind of complementary medicine, but also, and largely, because it is complimentary, in the compliment it pays itself.
The word ‘placebo’ has been glossed in a therapeutic context in two contrasting ways. First of all, according to H.G. Wolff, ‘The giving of a pill by the physician to the patient is the symbol for the statement “I will take care of you” ’ (Wolff et. al. 1946, 1719). But the future tense of the ‘I will please’ has also been seen as ‘a manifestation of the patient’s attempt to please the physician’ (Siegel 2002, 133). Who, then, is offering to please whom – and who is saying ‘please’ – or ‘if it please you’ – to whom? For Gunver Kienle and Helmut Kiene, the patient’s desire to please the doctor by saying they feel better, even if saying so actually seems to make them feel better, perhaps because it validates the institutional knowledge whence cometh that patient’s help, is actually a reason to rule it out as a ‘true therapeutic’ effect (Kienle and Kiene 1997, 1314). The plea and the promise seem to be, to borrow the psychoanalytic term, if not its interpretative assumptions, transferential, each making, and making good, its promise to the other, and vicariously making good the other’s promise. To adapt the dying Mrs Gradgrind’s groping speculation that ‘I think there is a pain somewhere in the room … but I couldn’t positively say that I have got it’ (Dickens 1998, 264) there is the offer of relief and recovery somewhere in the transaction negotiated in the consulting room, but it cannot positively be said quite where, or, naturally, when.
Formal promising requires the explicit use of the word promise, or some contractual equivalent like ‘vow’, ‘warrant, or ‘guarantee’: ‘I will meet you at 5.30’ cannot be held to be a promise in fact rather than in effect unless it is explicitly countersigned by a form of words such as ‘I promise to be there at 5.30’. Without this, the objection that ‘you promised in effect to be there by 5.30’ is illegitimate. But the placebo effect requires the promise to be the kind of promise ‘in effect’ that is not admissible as an actual promise. It seems to require that the promise remain implicit, without being ‘positively said’. Physicians who are squeamish about the possible charge of misleading their patients may adopt a lawyerish formula like ‘some patients find that taking this pill under medical direction brings improvement’, which may help to encourage a placebo effect precisely because it falls short of being a guarantee of success, while hinting to the patient that there would be benefit in being able to count themselves among the patients who experienced this desirable outcome. This might be an example, not so much of the ‘optimism of the will’ famously approved, following Roman Rolland, by Antonio Gramsci (Gramsci 1979, 159-60), as a kind of optimism of the imagination. After all, the patient is in the presence of the physician because they must already be allowing themselves to imagine being better than they are. Herbert Benson and Robert Friedman have suggested that this hope might better be characterised as ‘remembered wellness’, without, unfortunately, expanding on what they mean by this pregnant term (Benson and Friedman 1996). Medical science is much better at measuring what it means for a patient to be better, or worse than before, than at defining precisely what it might mean to be ‘well’, an adverb that is up to the elbows in implicitness (Connor 2023a. 5-6). Whether or not you are healthy can be determined by external measures, and perhaps can only be so determined. In order to be well, you need to be asked, or to wonder about yourself, whether you are or not. To say you are well, in response to an enquiry such as ‘how are you?’, or ‘I hope you are well’?, is to say that you know of no reason why you should regard yourself as unwell, now you come to ask, and as far as you can tell. This uncertainty is not a limit on your capacity to be and feel well; rather, it is an essential part of wellness itself. And yet this memory of what it means not to be suffering from a particular illness or infirmity, which means the knowledge of what it is like not to know of any such let or hindrance to one’s wellness (I am happy to be diagnosed with any kind of asymptomatic disease), may provide a very powerful kind of aspiration for patients, precisely because its meaning must necessarily be more implicit than explicit.
The history of attitudes toward placebo combines seductive fascination with uneasy suspicion. As the experimental basis of scientific medicine improved, so placebo, a word which came into use in the eighteenth century, in the period in which medicine was becoming institutionalised, tended to refer to the dubious methods and medicaments provided by quacks and charlatans. This history is recalled implicitly in the word ‘effect’, with which placebo is still often paired. The word ‘effect’, in use in English from the late fourteenth century, derives from Latin efficere, to accomplish or carry out, and names something brought about as the consequence of a cause. A law which ‘comes into effect’ is a law which becomes active, and to effect something is to make it actual, rather than potential. But, like the word act, which in this respect it doubles, the word effect can also mean the appearance or simulation of an effect, as in stage effects or special effects, this usage perhaps showing the influence of the verb affect in the sense of to assume a pretence. The first use of the phrase ‘placebo effect’ recorded by the OED is from 1902, in a discussion of the use of a decoction of boiled ants in the treatment of snakebite: ‘Formic acid is not known to have any value as a virus antidote, and there may have been a mere placebo effect about the procedure’ (Oswald 1902, 503). Much of the discussion of placebo during the twentieth century has centred on the question of how or whether the ‘placebo effect’ may in fact be regarded as a genuine effect, or a ‘merely psychological’ one, whatever we might mean by that. Placebo may perhaps be thought of less as a ‘stage effect’ than as a ‘side-effect’, less deception than accident. Since the first appearance of the term in 1814, a ‘side effect’ has usually been thought of, not only as unintended but also, perhaps as a result, undesirable. Placebo belongs to the smaller class of desirable or at least beneficial side-effects.
Placebo effects are frequently ascribed to what are referred to as patient expectations. This can be quite as true of customary or informal remedies as of the more accredited kinds of remedial procedure of conventional medicine. Siria Kohonen describes in detail folk healing methods for skin burns in the Finnish-Karelian tradition, involving the application of lotions, along with incantations and surprising procedures such as bringing the wound close to the heat of a fire, or applying salt to the lesions. She argues that such ritual procedures are effective because they align with the beliefs and world-view of the patient. This is scarcely surprising – though we should not ignore that fact that such worldviews can often include and mobilise the force of counterintuitive propositions, according to the somewhat perverse but widely-spread logic of the cathartic effect of ordeal: nasty medicines, especially for persons of my vintage, often have the reputation of being ‘stronger’ than nice ones. But the idea that symbolic repetitions, performing actions three times, or nine times (still at work in the instructions to ‘take three times a day after meals’, take antibiotics for five days, making sure you finish the course) ‘because of their psychological properties’, because ‘Repeating an incantation or an enactment a certain number of times reinforced the belief that the incantation would work, and this had relieving effects’ (Kohonen 2023, 58) really does not get very close to explaining what is meant by ‘expectations’ and, most importantly, how and why they might self-fulfillingly work. (As usual, there is a bottomless well of implication in the word how, which seems sternly to demand explication but rarely gets it.) A hint is perhaps to be found in the suggestion that the kind of magical beliefs and expectations at work in placebo are the ‘expressions of intuitive thinking’, characterised by ‘fast, reaction-based, and automatic interpretations of newly encountered situations’ (Kohonen 2023, 53). The suggestion made in Freud’s essay ‘The Uncanny’ that the magical thinking has an uncertain status in human cognition – everywhere powerfully at work, but also disclaimed and discredited, may offer a surprising clue here, for it may suggest that the placebo effect is powerful enough to grant its own wishes, not because of positive expectations, but precisely because the magical granting of wishes is, in the normal course of events, unexpected. The power of the ‘omnipotence of thoughts’ derives precisely from the fact that, because one can scarcely dare believe in them, they dare us to. The unlikeliness of magical outcomes can make them slightly but sometimes decisively likelier.
Placebo effects are intimately bound up with questions of knowledge. Although attention is focussed on the vehicle of the placebo effect – a powder, plaster or pill – it is really dependent upon the ritual of medical care, seen as the formalised enactment of knowledge. Placebo can be activated by ceremonial alone, but not by properties deprived of ceremonial. The application of ‘open-label placebos’ in which the patient is informed that the placebo is a chemically inert substance, depends upon the fact that the placebo is nevertheless ‘prescribed’ by the physician, with all that that implies and entails about the institutionally mediated process. The patient appeals and applies to the knowledge of what Jacques Lacan called the ‘one supposed to know’ (Lacan 1998, 232), whether they be seer, wizard or physician, who in their turn appeals to and applies the knowledge that is assumed by the patient to reside in them. This intermediary expert comes between the patient and their disease, but also, and perhaps primarily, comes between the patient and the diffuse but powerful body of the known, or found out. This knowledge is implicit for the patient, but involves the trust that it is explicit knowledge for others assumed to be ‘in the know’. To be a patient is to know that you do not know, while knowing, or at least being confident (a word that quivers with co-implication), that there are others who do. The folk assumption of third-person, proverbial knowledge embodied in the phrase ‘they say’ – they say that an apple a day keeps the doctor away – passes readily across into the scientific first-person singular of ‘we tend to find that’, which reassuringly combines abstraction (medical experts in general) and intimacy (other doctors I know).
Though the knowhow of the nurse or practitioner is crucial, they do not in fact know how their knowhow can induce in the patient a corresponding physical knowhow that is enough to produce distinct and measurably biochemical effects. This set-up meets some of the conditions defined by Michael Polanyi as tacit knowledge: both parties in the treatment know that an effect can be produced without knowing precisely how, and so, in Polanyi’s dictum, ‘know more than they can tell’. I know how to ride a bike without knowing how I do it, or how what I do when I do do it works. In the bicycle made for two of the placebo performance, the patient and their consultant both look neat upon the seat, but neither knows quite what they or their partner is doing to keep the wheels turning or the whole kit and boodle upright and moving.
Placebo is of little direct use in the case of toxicity, serious infection, limb fracture, blunt trauma, heart attack, organ failure or broken limbs, but is so powerful as to be almost impossible to avoid in the case of conditions with a prominent psychological component, such as depression, anxiety, pain, asthma, gastric illness. nausea or insomnia, and the differential responses to treatment of the more intractable kinds of physical injury or ailment. And let us not forget that all serious and indisputably physical kinds of injury or ailment involve periods of recovery in which placebo effects are close to being indispensable. To adopt a formula offered by Harry Beecher, placebos ‘have an important part of their action on the reaction or processing component of suffering, as opposed to their effect on the original sensation’ (Beecher 1955, 1602). Placebos ease ailments by allowing for the remaking or modulation of what patients are making of them in their mode of ailing.
My hope in this chapter is to suggest that, at least in some forms of placebo, and possibly in many, the placebo effect accompanies a productive tension between explicit and implicit knowledge, between knowledge that patients have, or have accessible to themselves and knowledge that is delegated or attributed to others, or otherwise supposed to reside in them. It is not just that there is more in placebo than meets the eye, it is that placebo may in some way depend on or derive from just this explicatory deficit. It is not that the patient does not know what they are doing, or how, since they cannot themselves be said to be doing anything, even if something is nevertheless being done in, about, by or through them, even if it not being done by or to them. Placebo is a prepositional enigma (from Greek αἶνος, apologue, fable, riddle), of by, through, from and with, which perplexes the tête-à-tête of subject and object that is dominant in explicit thinking about actions and processes.
The question that has begun to preoccupy writers about the placebo effect is whether placebo can be relieved of this veil of ignorance and its workings rendered wholly transparent, the implicit thereby made fully explicit, and so operational on demand and optimisable. Rather than employing the mechanism of the medical trial, which takes account of placebo in order to isolate it and to subtract its effects, this kind of enquiry aims to draw up the implicit workings of placebo into explicitness.
Ritual and Knowledge
The expert is not only the one supposed-to-know but also supposed to know what to do. As W.R. Houston proposed in 1938, ‘what the patient most imperatively demands from the doctor is, as it always was, action’ (Houston 1938, 1419). Expert, from Latin experiri, to try or put to the test, related to a conception in Greek of passing through, as in περάω, pass through and πόρος, passage, meant one who has what we call ‘hands-on experience’, though the term has tended from the nineteenth century onwards to move from the practical to the theoretical.
The performance of the cause-and-effect action involved in the treatment, whether it mimes the drawing-out of the disease, as in more histrionic forms like trepanning, psychic surgery, or the application of the ‘Perkins tractors’ of the late eighteenth century, metal pins which, when drawn across the body seemed to relieve symptoms of rheumatic pain and paralysis (Miller 1935), where tractor shares with treatment an etymological origin in Latin trahere, to draw or pull, gives an objective correlative to the idea of cure or relief . Cure consists of taking things away, while care consists of keeping people comfortable until they go away of themselves. A leading principle of care and cure has, in many different times and places, been thought to be that it is cathartic, or purifying, and Stewart Justman observes that ‘healing has long been thought to operate by clearing harmful things from the body, whether by means of purging, bleeding, or some other method’ (Justman 2013, 12).
It used to be thought that any relief of symptoms was ‘purely’ the effect of the patient’s imagination, but more recent investigations have been able to show that the contagion of cure is enough to trigger the release of neurotransmitters like endorphins or dopamine in the brain and body which mimic those used in physical medicines. Nobody seems to think this might also operate in the other direction – that physical cures might be effective because they ‘mimic’ endogenous processes. The explanations as to how this is supposed to be brought about tend to rely on pseudo-explanations rather than on clear demonstrations of how the process might work in actual practice: ‘Honest placebos work because of our subconscious expectations. Our past experiences of doctors and hospitals can generate subconscious expectations that activate our body’s inner pharmacy, which produces morphine (endorphins) and other beneficial drugs’ (Howick 2024). The words ‘because of’, ‘generate’, ‘activate’ and ‘produce’ in the above sentences are all miniature black boxes, which state that effects take place without any account of exactly how they take place The words imply a mechanical process, but they have the magical implication of the pseudo-mechanical, that which happens autonomously or automatically, rather than the explicitly mechanical, that is, specifying the nature of the mechanism. Like the dormitive faculty of opium in Molière, they work because of their ‘operative faculty’. I am reminded of a cartoon by Sidney Harris which appeared in the November-December issue of American Scientist in 1977: two mathematicians are standing in front of a complex sequence of equations scrawled on a blackboard, in the middle of which are written the words ‘then a miracle occurs’, at which the elder mathematician is pointing , gently murmuring ‘I think you should be more explicit here in step two’ (Harris 1977, 42).
In the seventy years since the appearance in his essay ‘The Powerful Placebo’ of Harold Beecher’s dramatic claims regarding the extent and prominence of the placebo effect (Beecher 1955), a considerable amount of commentary has accumulated which argues that the placebo effect may hardly be in operation at all where it is thought to be. In 1997, Gunver S. Kienle and Helmut Kiene reanalysed a spread of placebo literature and found a wide range of errors and mistaken assumptions ‘which produced false impressions of placebo effects’ (Kienle and Kiene 1997, 1311). These included failure to take account of spontaneous improvement, fluctuation in symptoms, and conditioned reflexes. The implications of this are intriguing, for, where ordinarily the placebo effect transmits confidence from the doctor to the patient, here the placebo effect seems to be transferred from the patient to the doctor. In either case, though, some effect seems definitely to have occurred.
Confidence
Normally, placebo effects seem to occur when patients do not know that they are taking dummy pills, or what are called ‘inert’ substances. Recently, impelled by a certain ethical squeamishness about the dishonesty or deception this introduces into the doctor-patient relation, attention has begun to be paid to placebo effects which seem to be able to occur when patients are fully informed about the nature of the medication they are taken, but reassured authoritatively that they nevertheless seem to have benefited other patients. This has led in turn to speculations on how the patient may internalise the epistemic dramaturgy played out between them and the doctor as representative of medical knowledge, turning sociotechnic into personal technique (Pagnini 2024). Joan, an academic engineer of my acquaintance revealed in conversation that she regularly had recourse to acupuncture, and, when gently rebuked that, as a professional scientist, she should know better than to trust to the dubious explanations given for acupuncture’s effect, involving flows of qui and luo along bodily channels and meridians undetectable to any human eye or apparatus, replied cheerfully, ‘Of course I know all that perfectly well, but I also know it’s just the kind of thing my body will go for’. This seems to me to be charming, witty, forgiving, large-minded and wise. I particularly relish the thought that the body of a career-engineer might be particularly susceptible to a theory based, as acupuncture is, on such an impressively intricate, if also entirely imaginary, system of bodily pneumatics. It resembles the story told in many versions of the physicist Niels Bohr, who replied to a visitor expressing his surprise at seeing a lucky horseshoe hanging on his door, ‘I’ve sometimes noticed that it works even when you don’t believe in it’ (Anon 1956, 422).
The implicit is at the heart of the history of thinking about placebo, as indicated by the intriguing opening sentences of Arthur K. and Elaine Shapiro’s The Powerful Placebo: ‘It is a mystery how a ubiquitous treatment used since antiquity was unknown, unnamed, and unidentified until recently’ (Shapiro and Shapiro 1997, 1). For, though ‘unknown’ and ‘unnamed’, the effectiveness of what is now known and named as the ‘placebo effect’, according to the Shapiros, ‘has been attested to, without exception, for more than two millennia’ (Shapiro and Shapiro 1997, 1). Attesting here can only mean something like showing rather than saying, testifying through appearance and effect rather than declaration, in an implicitness which, oddly, seems both more and less direct than explicit assertion. Attestation is from Latin testis, a witness, one who bears witness explicitly in court, apparently deriving from a Proto-Indo-European *trito-sth2-o- ‘third standing (by)’ (Vaan 2008, 618), though testicle, as a diminutive of testis, has sometimes been explained as a physical witness to or token of virility. All of this makes one wonder, and wonder how to decide, whether medical implicity is a kind of simplicity or a kind of duplicity.
So here is something that looks like a paradox, which is dramatised conveniently in the case of antidepressants. Joanna Moncrieff in The Myth of the Chemical Cure: A Critique of Psychiatric Drug Treatment (2007) and Chemically Imbalanced: The Making and Unmaking of the Serotonin Myth (2025) is opposed to the idea that depression is a brain disease and can best be treated by antidepressants which address the alleged ‘chemical imbalance’ which has caused the depression. But what if you are somebody who is persuaded that there may be ‘endogenous’ – as they used to be called – as well as contextual factors which cause depression? You might therefore be likely to be helped by anti-depressants precisely because of the faith you have in the explanation of how they are working, even if this were a placebo effect – in fact, especially if it is this kind of placebo effect, and especially if the placebo effect is strong enough to be worth having. So, even though antidepressants may not work in the way in which they are believed to, the belief that they work in this way may itself be important in exerting the placebo effect which is itself the disproof of the belief that is required for it to work. You may in short, need to believe that depression is a brain disease in order to be able to act on the fact, without knowing how you are doing so, that it is not. The idea of a ‘chemical imbalance’ may indeed be mythical, but this is to say, as with most myths, that it is epistemically weak but affectively and performatively strong, as witnessed by the continuing success of similar ideas of bodily harmony and discord across many systems of medical thought.
This kind of paradox is in fact at the heart of all placebo. Like ventriloquism, you have to believe that it is happening on its own, independently of you, when you are in fact doing a lot of the work, without really knowing how you are doing it. This kind of misprision or self-misdirection seems to be essential to the placebo effect, since it seems much more likely that you will be able to perform this therapeutic work on, and for yourself, if you believe that it is in fact an external effect, validated by medical practice, as it might once have been validated by tradition or religious doctrine that certain accredited persons understand better than you do. When you first succeed in riding a two-wheeled bike, it is traditional for your father to hold the seat with one hand as he jogs alongside you, and then surreptitiously to remove it to prove that you do not need it. This exteriority is likely to take a biochemical form nowadays, but need not necessarily. All that matters is that there should be something or someone that is ‘in the know’, or ’supposed to know’, in the phrase thrown out by a psychoanalyst who was himself in such a good position to know about it. And something that works on you whether or not you believe it has the huge tactical-affective advantage that it mimics the essential nature of the illness that it aims to overcome, in being a not-I that is stronger than I am: only a good, restorative not-I will avail against a bad, destructive not-I. Not being able to be sure who or what precisely is effecting the effect and how seems to be an irreducible ingredient in the workings of placebo. Something is at work in the consulting room, without anybody being able positively to say that they are working it. It seems that you can only put into placebo the powerful work it requires and of which it is capable if there is a trust, or pretence, that something else more straightforwardly explicable is in fact doing the work.
This accounts for the essential queasiness that characterises the many discussions of placebo. It dramatises a divide between theory-driven explicators and pragmatic engineers. Both are driven by a desire to do good and do no harm, or as little as possible, in the process, and nobody can be wholly or solely one or the other all of the time. For impelling and unexceptionable reasons, explicators want to be able to explain how the products and processes applied in medical care work. The example of treatments applied according to purely magical forms of logic in the past, many of which have exposed patients to terrifying risk of harm – opium in children’s cough mixture, mercury for syphilis and so on – imposes a deep responsibility on medical science to be open and transparent about how and why treatments work. For explicators, implicit understanding is just as much the enemy as disease itself, which is why medical treatment over the last century or two has made such astonishing progress, and why medical research plays such a leading role in the regime of explicating the implicit identified by Peter Sloterdijk as the governing principle of modernity, in a self-doubling act of explicitation.
Engineers, by contrast, are not opposed to the process of explication, but do not believe that a procedure is necessarily worthless, dangerous or illegitimate until it has been fully explicated. The more hard-line kind of engineer may anyway be inclined to doubt that it will ever be possible fully to purge every particle of implicit assumption from the process of explication, since explanations can anyway only ever be explanations that are good-enough so far and for certain purposes, according to assumptions of a deep-laid kind of implicitness as to what explanation is. The disagreement between explicators and engineers resembles, as so many disagreements do, that between Protestants and Catholics, or, more precisely perhaps, that between Puritans and Anglicans, in which the question of what mediates the soul and its Creator is always at issue.
Joanna Moncrieff exemplifies the position of the explicator with regard to antidepressants, taking the view that not knowing how they work may well mean that they are doing harm. It must, to be sure, be admitted that this can often be the case. The glass-half-empty view of the explicator is the claim that antidepressants are ‘no better than placebo’, which, given the huge and still growing number of antidepressants that are currently prescribed certainly sounds unnerving. The glass-half-full view of the engineers who believe that antidepressants can be helpful, even though we do not know exactly or in full how or why, is that, despite these limits on our knowledge, antidepressants appear to be ‘no worse than placebo’, or even ‘almost as good as placebo’, which, though it may sound like faint praise to the explicator, may nevertheless appear to be a rosier prospect.
If studies of placebo declined in the period extending roughly to the mid twentieth century in which medicine consolidated its power and reputation via its mastery of an ever more detailed physiological account of illness and treatment, the considerable upswing in academic interest in placebo since the 1950s has come in parallel with challenges to this dominant model and the growing popular authority of complementary or, put less politely, alternative kinds of treatment. Psychological explanations of placebo have given way to anthropological explanations, which stress the fact that the understanding of the physical world must always be mediated by social-symbolic structures of what is taken for granted about the world. In place of the idea that there might be more or less suggestible ‘personality types’ in whom placebo effects might be more or less powerful, Daniel E. Moerman points to the variable effects of placebo in different cultures of social groups, in summarising, for example, the outcomes of Margaret Lock’s research on the experience of menopause among Japanese women with the statement that, though some of the symptoms of menopause are reported by Japanese women, though at much lower levels than by women elsewhere, ‘menopause as a medical condition generally doesn’t exist in Japan’ (Moerman 2002, 74). There would seem to be no reason to believe that Japanese women undergo a different biological process during the period of the cessation of the menses, which is known in other countries is known as the ‘menopause’, though much less attention is paid to this period of endocrinological adjustment in Japan, and Japanese women report much lower levels of the symptoms held to be characteristic of it elsewhere. There seems for example to be no specific word in Japanese for what is the most well-known and prominent symptom of menopause in other countries, the ‘hot flash’ (or, as they are generally known in the UK, ‘hot flush’) (Lock 1986, 33).
This may be less dramatic than it sounds, amounting to a difference, not in biology, but in social categories. Thus, the thing, or collection of things, elsewhere called menopause certainly exists in Japan: but, though menopause exists, ‘menopause’ does not. However, Moerman collects evidence which seems to go much further than this, to show that, not only does illness mean different things to different groups of people, that difference of meaning can be accompanied by, and, as it seems, produced by what seem like biological differences. Not only do people with duodenal ulcers prescribed placebo, or undergoing placebo procedures, report feeling better, endoscopic observation shows that their ulcers actually heal better than in patients who have received no treatment. Blood pressure can be reduced by taking certain kinds of medication, but it can also be reduced by placebo at comparable rates (Moerman 81). Moerman stresses the importance not just of traditional customs and beliefs in placebo but also of different kinds of knowledge, or, perhaps more precisely, what people in different groups believe they know about what ‘is known’ by others. This knowledge appears to be both highly specific and well-nigh indispensable in the workings of placebo. Sham surgery, nowadays forbidden in the UK, in which surgeons go through the motions of surgical procedures without actually performing the operation, only ever works when patients know it is happening, Sham surgery, especially under general anaesthetic, is particularly striking for my purposes since it dramatises very neatly the interaction of knowing with not knowing, since the patient knows for sure only that some surgical procedure has taken place, without knowing what. One might say that this a metaphorical principle of ‘general anaesthetic’, or ‘general anepistemic’ that is at work in much placebo. Moerman strikingly extends this principle from patients to doctors, to describe the effect of what, in a psychoanalytic context, might be called a collateral, collusive or complicit ‘transference’ between patient and physician:
the single most important source of knowledge and meaning for patients is their doctors. Doctors know lots of things. Many of the things that they know they are unaware of knowing (as is true for most of us in this life). But it is the depth of their convictions which conveys to patients the power of their treatments. (Moerman 2002, 46)
Moerman’s investigations undoubtedly bring much to light regarding the operations of placebo, and shift attention from the placebo effect to what he calls ‘the biological consequences of experiencing knowledge, symbol, and meaning’, or the ‘meaning response’ (Moerman 2002, 4). Moerman concludes one of his chapters with the assurance that ‘The same item (a cimetidine tablet, or a placebo cimetidine tablet) can be expected to mean different things in such different places, and, therefore, it can be expected to have different effects there’ (Moerman 2002, 85). The ’therefore’ in that sentence is mightily presumptuous. But why should these effects be expected? And how are those effects effected? Just as much to the point, why are they effected in medical contexts in ways that do not seem to be possible in other contexts – through prayer, for example? Why would we find it implausible, to take only one example of many possible, that people could be able to change their appearance, eye-colour, say, or height, or the signs of ageing, at will, through the exercise of physiognomic intent or optimistic expectation? The increase of knowledge Moerman offers in the area of meaning, in the sense of ‘what things signify’, leaves the area of meaning as ‘meaning to do’ or practical intending, as much in the dark as ever, or perhaps by contrast even more than before.
Wherever we may come to rest in our thinking about placebo, it seems likely that there will be some residual black-box, of which we can specify the input – meaning – and the output – therapeutic effect – without our being able to illuminate precisely and comprehensively what is happening inside the box. What makes this even more intriguing is that this explicatory shortfall seems to have something important to do with the process itself. Placebo provides a telling and compelling example of the ways in which the known and the unknown do not form a simple zero-sum game, which allows id, or the It (das Es) to be lifted up into ego or the I (Ich), but are rather co-implicated in an economy of relative forms of the known and the unknown, or the explicitly known and the implicitly known.
Nice though it might be to be able fully to explain the workings of placebo, that explanation is likely to have to encompass some measure of acknowledgement that explanation, as epistemic catharsis or driving out, especially in a world so fanatically pledged as ours to the work of explicitation, or driving of the implicit into visibility and sayability, has its own kind of magical aura, in which keeping its own counsel is a large part of what can be expected from the consultation.
Almost all of the thinking regarding placebo rests on a powerful and largely unexamined assumption, that ill or injured people wish to be well. But, of course, we are all familiar with the fact that there is another way of pleasing a patient, and of a patient pleasing a doctor, namely through being unwell, or all the manifold ways in which one moves from the condition of being unwell to the condition of being a patient. This has come to be known as the ‘secondary gain’ of illness (Egmond 2005), though it scarcely needed, or needs, any kind of technical designation, for anyone who has ever observed a toddler with a grazed knee reaping and prolonging the rewards of their discomfiture. The very word patient, which has been used as a grammatical term, as an alternative for the passive mood of a verb, implies a kind of action in inaction, an undergoing that is a kind of doing. In the surgery, the patient and the doctors both have jobs to do.
Despite the gleeful reporting in the Daily Telegraph of cases of people claiming benefits for incapacitating conditions who are then photographed pole-dancing or playing rugby, this need not be regarded simply as a species of malingering or deception (Egmond, Kummeling and Balsom 2005). For the secondary gains are by no means always obvious kinds of advantage. One example may be the new importance of the diagnosis. Where patients from mysteriously stubborn ailments might a couple of centuries ago have travelled from spa to spa seeking cure through various kinds of treatment, the aim of many patients at the present is to acquire the status of patient via a diagnosis. What is more, the status of the diagnosis has changed. Where in the past it was important to know precisely what was causing one’s symptoms the better to know how to treat them successfully, nowadays the diagnosis is often experienced as the end of the journey, and as a kind of cure in itself. My envious wish to have written the following sentence means that I take every new opportunity to recite it: ‘Sticklers have been met with who had no peace until they knew for certain whether their carcinoma was of the pylorus or whether on the contrary it was not rather of the duodenum’ (Beckett 1973, 243). It is striking how little in the way of attempted remedy tends to follow the conditions for which patients seem most anxious to obtain a diagnosis. The cases of ADHD and autism dramatise the seeming fact that diagnosis seems really to be a demand for an acknowledgement of a style of being – may we call it a recognosis? – which assumes sympathetic respect and perhaps programmes of therapeutic attention but no expectation of any kind of cure.
I do not think the explanation towards which Freud leaned, that the need to be ill is a dissimulated form of the guilty need for punishment, is likely to be operative in many cases of the demand for diagnosis. The superego seems to have become much cannier in its operations than it was at the beginning of the twentieth century. Nor am I entirely sure that such a need involves any of the dynamics of placebo. It perhaps earns its keep in such a discussion as this, if only as the kind of afterthought I am currently offering, because of the way it shares in the redistribution of subject and object roles, professional and patient, When the placebo of diagnosis replaces the placebo of prognosis – putting us perhaps in need of a term like recognosis? – Lacan’s ‘subject supposed to know’, (‘sujet supposé savoir’, or S.s.S) will have become a shuttlecock subject of sustained reconnaissance (Lacan 1998, 232).
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