by Richard Kradin; New York, Taylor & Francis, 2008, 296 pages, $40
Dr. Dixon is director, Division of Health Services Research, University of Maryland School of Medicine, Baltimore.
One of the great mysteries of medicine is the placebo effect. As health care providers, we are ambivalent about it. Is the placebo effect a tool in our toolkit, or is it an indicator of our ineffectiveness? Is it something to celebrate and master, or is it something to hide from the world? Richard Kradin's book is a fascinating exploration of the placebo effect, satisfying for both the biological scientist committed to the primacy of neuroscience and for the clinical therapist, comfortable with the vagaries of the world of feelings and beliefs that provide the foundation of human relationships.
With his background, Kradin is uniquely suited to write this book. He is a trained psychoanalyst and has contributed academic articles in the psychoanalytic literature. He is also a medical internist, immunologist, and pathologist, treating cancer patients with innovative immunotherapies. He illustrates his points with compelling anecdotes from the world of cancer treatment. Tumors disappear and reappear, seemingly as a response either to belief in the physician team or faith in the treatment, or lack thereof.
The placebo effect is of special relevance in psychiatry because many of the treatments produce a large placebo response. It is also of special relevance because at least some of the placebo effect is attributable to the therapeutic relationship between care provider and patient—something on which we spend a great deal of time and effort focusing in our training and supervision.
The volume is divided into chapters that almost stand on their own and can be read or not read, depending on one's interests. Each chapter is very dense, and readers should take their time to absorb the content. The first few chapters define the placebo response and describe its rich history in medicine. Kradin challenges our comfort with plain statements, such as "Many lay people harbor the erroneous notion that physicians know how most treatments work." He explains the advances of modern medicine but does not let his readers off the hook. He explains the advantages of randomized clinical trials but also their limitations. We are left pondering the question of what it means for a treatment to be better than placebo.
The middle three chapters focus on the science of the placebo response. What kinds of people develop a placebo response? Here Kradin makes the case that most people have the capacity to develop a placebo response, which he characterizes as a state rather than trait behavior. Some readers might skim the chapter on what we know regarding how placebos act, depending on their background and interest in neuroscience.
The final three chapters provide intellectual exploration and synthesis about the placebo response. A compelling discussion of the ethics of the placebo response reveals some mind-bending paradoxes. Ultimately, Kradin's consideration of the placebo response underscores our awareness of the truth of humans as both independent and dependent, as both isolated and completely connected. Kradin's book is both scientific and spiritual.