I have tried to make a coherent presentation of an argument for meaning in medicine. It should come as no surprise to know that, gently phrased, “others disagree.” This is a highly contentious and rancorous business sometimes. In this chapter, I want to show some areas in healing which are similar to the meaning response, but can't be explained by it. I also want to compare the meaning response with other approaches which might overlap with what I have described, and to suggest that the differences may be as much semantic as anything else. In any case, here are some limitations and challenges to the meaning response.

“Conditioning” placebo effects

Dr. Fabrizio Benedetti has done another quite remarkable experiment (Benedetti et al. 1999). It's not easy to explain, so watch carefully. One of the dangers of narcotic painkillers is that one of their “side effects” is to depress respiration; they reduce your ability to breathe. In this experiment, sixty people with lung cancer were having surgery to remove portions of the lung. After the surgery, they were given a narcotic (buprenorphine) through a saline drip. For three days, they would receive a fairly large dose of the narcotic in the morning, and then a much lower dose throughout the day. Dr. Benedetti measured the patient's respiration each day just before the morning dose of narcotic, and then an hour later; he measured the volume of air (in liters) that the patient breathed in a minute.

Even fictional doctors know that their patient's attitudes and understanding of medicine and treatment are a fundamental part of the healing process.

An ulcer trial

In the early 1990s, Dr. Frank Lanza, a gastroenterologist from Houston, Texas, led a large team of doctors in a test of a new drug for treating ulcers. Over 300 people participated in the trial which compared the effectiveness of a new drug known as lansoprazole (its trade name is “Prevacid”) with another, older, drug for ulcers called ranitidine (“Zantac”). The people who entered this study were diagnosed with ulcers by having a procedure called an endoscopy. In this procedure, a fiber optic tube - an endoscope - is put down the patient's esophagus, and a technician examines the wall of the gut on a little television screen. In each case, only after the technician saw an ulcer in the patient's stomach was the person admitted to the study.

Human beings respond to injury in three ways. Autonomous responses are the most important ones in healing, and involve all those processes which the organism can invoke to regain health or equilibrium, including the various immunological and related systems. A cut finger rarely needs much more than to be rinsed in water (or licked clean), and it will heal “by itself.” Specific responses are those of the body to the content of medical treatment - to the salicylates in willow bark tea, or to the antibiotic quality of penicillin. The direct pressure of a bandage on a cut finger might facilitate its healing. Meaning responses follow from the interaction with the context in which healing occurs - with the “power” of the laser in surgery, or with the red color of the pill that contains stimulating medication. Sometimes, a bandage on a cut finger works better if it has a picture of Snoopy on it. These three sorts of factors all work together to enhance the sick individual's return to health.

Pain relief with “Trivaricane” and saline solution

To illustrate this threesome, I will describe the results of some research involving pain. Now pain is a tricky thing to deal with. I can't see or measure pain; I can only listen to what you say about it. And asking you about your pain is likely to change its intensity.

I haven't mentioned it very often, but there are many ethical issues which people routinely raise about placebos. This has been a perennial problem in medicine, I think. The primary problem is that, historically at any rate, when doctors really didn't know what to do for a patient, or simply didn't have any treatment which they thought might be effective, they often gave people inert drugs: bread pills, sugar pills, whatever. In a famous passage from a letter to a physician in 1807, Thomas Jefferson wrote: “One of the most successful physicians I have ever known, has assured me, that he used more bread pills, drops of colored water, & powders of hickory ashes, than of all other medicines put together. It was certainly a pious fraud.” Jefferson is forgiving, but he does credit this action to be a “fraud,” even if a “pious” one. That the use of placebos seems somehow “fraudulent” is a serious problem for medicine.

The case of the Kwakiutl shaman

One of the great cases, which raises many important issues, can be found in anthropologist Claude Levi-Strauss' famous paper “The Sorcerer and his Magic” (Levi-Strauss 1967b). In it, Levi-Strauss analyzes the case of Quesalid, a Kwakiutl Indian from Vancouver Island in British Columbia, a case originally reported a generation earlier by Franz Boas (Boas 1930). Quesalid had reason to believe that the shamans were cheats and frauds, shamelessly exploiting their patients with trickery.

In the next two chapters, I will look closely at two areas where meaning is particularly effective: psychotherapy and physical pain.

Everyone has won and all must have prizes

Psychotherapy is a complex and contested business. Few doubt its effects, but many (at least many outside the field) are unsure of how to think about its effectiveness. Indeed, some have argued that psychotherapy is “only” the placebo effect. I will argue that this is good reason both to stop using the concept of the placebo effect in such a way, and to start thinking about the meaning response.

How does psychotherapy work? The simple answer is, “No one knows” (Dawes 1994:61-2). This is quite surprising and seems at variance with experience. Anyone who has ever peeked behind the surface of any sort of psychotherapy knows that practitioners have very strong views of how and why their practice works. Don't psychoanalysts know how their therapy works? Surely the behaviorists know what they are about and how things work. Of course they do, in some sense. But the problem is that both of these systems work, they seem to work more or less equally well, and they work equally well for the same sorts of problems.

There are huge differences in the attitudes, approaches, and theories underlying the different therapeutic schools - Freudian psychoanalysis and Skinnerian behavior therapy are about as different as one might imagine two approaches could possibly be when addressing, say, compulsive hand washing.

Telling stories about our lives, or creating meaning from grief, can affect our bodies, our biology. Such meaning responses can occur within a broad range of medical or health phenomena: heart disease, ulcer disease, immune diseases, and so on. But the best-known biological system which displays impressive meaning responses is the body's pain system. This chapter will review the neurobiology and the cultural biology of the human pain system and show how meaning can influence the experience of pain.

Neurology of pain

Pain is an extremely important biological process, a powerful signal an organism uses to signal to itself that “something is wrong.” To lack a sense of pain is to open yourself up to injury which, unrecognized, could easily be fatal. Pain is a primary device for learning. Unfortunately, the pain system can occasionally go awry, causing more trouble than it resolves. In this brief review we will touch only the high points, but you should gain some sense of the value, and the problems, of pain.

Some time ago, Dr. Alan Leslie summarized the case of a very sick man.

These sorts of things - from blue pills to lasers - are all things which we “know,” even though, like the goldfish, we may not realize that we know them. Much of our knowledge of the world is not an elicitation of what “is,” but rather it is a construction laid atop the world of experience. This is a very difficult concept for many people to grasp. The world that we see and experience seems so palpable and true, and our conceptualizations are so deeply entwined among themselves, that it just seems fantasy to say that the reality I perceive is largely metaphor and construction and is largely projected onto (rather than observed in) the world. These things are generally true, and they are true for many matters of health and medicine. This chapter may not convince a skeptic. But it may encourage the enquiring, and its goal is to make the strangeness of the placebo effect and the meaning response somewhat less strange. The price to be paid is that everything else gets rather more strange. C'est la vie.

Proper meals, clothing, pills

In the United States, we “know” that one eats (or, ought to eat) three meals a day; if you don't, your mother gets mad at you.

I have made many claims in this book. Some of them are quite straightforward, while others are more anomalous. Some have lots of good evidence, while some have less. Some issues seem clearly nailed down, while for others I have said that “more research is needed.” Now I want to summarize the whole picture of the meaning response, and indicate what we need to know most to make this powerful human process more understandable, and maybe even more useful.

People live in rich and complex worlds of their own construction. Whether they are nuclear physicists, Jesuit priests, or members of the Taliban in Afghanistan; British, French or German; Navajo, Seneca, or Maya; in any case, people view the same world in many different ways, making sense of it, making it meaningful in many different ways. It is easy to overstate the case for cultural differences: all societies have families, provide food, speak languages, and share understandings. But the differences remain profound; I would argue, for example, that these differences are far greater and far more important than any genetic variations among human beings. What might appear to an outside observer to be very minuscule differences (e.g., that the bread and wine “are” the body and blood of Christ rather than that the bread and wine “represent” the body and blood of Christ) can be matters of enormous importance (the issue of “transubstantiation” was - indeed still is - probably the most important theological issue in the many disputes of the Protestant Reformation).

Blessing Way and Placebo Way

One of the most complex medical systems which people have developed is that of the Navajo in the four-corners region of the American Southwest. It is very common for human religious systems to revolve around elaborately ritualized meals where food is shared; the most obvious example for most readers of this book will be the Catholic mass, or similar communion ceremonies of other Christian groups, or the Passover Seder. Such shared meals are the center of ceremony in many other cultures and religions as well. The Navajo are an exception to this generalization. They do not have a meal at the center of their most significant religious rituals, but rather what we might call a visit to the doctor's office. The core of their religious life is a healing rite known as a “chant way.” There are many different ceremonies used for different purposes: among them are Wind Way, Female Shooting Holy Way, Hand Trembling Evil Way, and, probably the most frequently carried out, Blessing Way. I have never found a short description of these Navajo ceremonials which seemed to describe them accurately.

A typical chant way comes in several versions; it might last for two nights, five nights, or nine nights. The ceremony includes a rich complex of medicinal plants (as many as a hundred or more may be used in several different mixtures for a variety of purposes), prayers of consecration, offerings, baths, sweat baths, sandpaintings, singing all night, and so on.

The most important aspect of any medical experience is its content. Whether a physician or healer prescribes aspirin or penicillin, willow bark tea or quinine, the most crucial thing is that the drug has some sort of active ingredient which interacts with the body, the immune system, a pathogen or the like, to facilitate recovery. But the content of medicines is not the only thing that counts. We have just reviewed the effect that physicians - their knowledge, their enthusiasms - can have on treatment. The form of medicines, their color, shape, and amount, makes a difference, too.

Meaningful pills (pink and blue ones)

In the early 1970s, several professors at the University of Cincinnati medical school devised an interesting experiment for their students (Blackwell, Bloomfield, and Buncher 1972). Fifty-seven second-year medical students agreed to participate in what they were told was a study of two new drugs. Each student would receive either a stimulant or a sedative. They were told the ordinary effects of these drugs. For example, they were told that “a sedative drug usually makes the individual feel more relaxed, calm and easy-going, but some people react by feeling drowsy, sluggish or tired. There is a tendency toward a decrease in pulse-rate, pupil size, and arterial [blood] pressure.” The students were randomly divided into four groups. These groups received, respectively, one or two pink or blue tablets; the tablets were, in fact, inert.

It is clear that what I refer to as the meaning response is far larger and more significant than what happens when people take placebos. Figure 12.1 shows a representation of the relationship between the two situations; they overlap in an important way. Both the placebo effect and the meaning response involve more than simply the reactions of people to inert medications. People taking placebos in an RCT may exhibit regression to the mean (or movement to homeostasis), or bias, or more. Similarly, the physiological or psychological response to meaning - the meaning response - occurs in many more areas than clinical trials.

Sightings

Other authors have extended this net even further than I have. Harvard historian Anne Harrington has described what she calls “sightings, … fauna that live in the same larger territory of human psychobiological functioning in which the placebo effect makes its home as well” (Harrington in press). Among her sightings are these:

• “A room with a view.” A study at a suburban Pennsylvanian hospital showed that surgical patients who stayed in a room with a window view of a natural setting got better faster than a matched sample of patients who had a view of a brick wall (Ulrich 1984).

• “Psychosocial dwarfism.” A number of studies in the US and Europe have shown that children deprived of a secure bond with a loving caretaker - children in orphanages or abusive situations (even those whose material needs are met) - may grow up physically stunted. They have been shown to have reduced levels of growth hormones. Simply removing them from the situation and providing them with a loving secure home (probably involving people who will talk with them, that is, make life meaningful) can be sufficient to reverse the damage (Mouridsen and Nielsen 1990).

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