The Yale Journal for Humanities in Medicine

The Placebo Disavowed: Or Unveiling the Bio-Medical Imagination
(continued)

Ed Cohen
edcohen@rci.rutgers.edu

The first known use of “placebo” in a medical context occurs in 1785 in the second edition of Motherby’s New Medical Dictionary where it designates “a commonplace medicine or method.”[xvii] For the next 150 years, the word was employed to disparage treatments that were understood to derive not from sound medical principles but were rather dispensed in order “to please” the patient and thereby curry both favor and income. The assumptions underlying this usage are twofold: 1. There is a distinct though not always visible threshold that marks the difference between authentic and inauthentic treatments and hence between authentic and inauthentic practitioners; and 2. Lay people will not be able to distinguish among authentic and inauthentic treatments and authentic and inauthentic practitioners because they are susceptible to being “pleased.” Leaving aside the obvious condescension and self interest that percolate through these assumptions, one might want to ask in what sense does the placebo “please”?  For even if a placebo is, bio-chemically speaking, useless (i.e., an inert substance or a mere nostrum) it still must have some efficacy in order effect “pleasure” and thereby circulate as a commodity. In other words, it must appeal to someone or something in order to function as a placebo. Thus, we might need to inquire: to whom or what does the placebo’s “pleasure” appeal?

To speak of the placebo’s pleasure is to underscore the element of desire that it necessarily engages. In our species, an experience of illness often evokes not just an organic impulse towards physiological homeostasis, but also an active desire for amelioration and care. This reflexive relation to the bio-chemical events that constitute both disease and healing at a cellular or molecular level suggests that our subjective experience is always already part of the organismic processes that we call our lives. It is in this sense that Candice Pert, the path breaking bio-chemist who “discovered” the opiate receptor in the brain, considers the human organism as a hybrid “bodymind” where physiological, psychological, and emotional phenomena are mediated by the molecular action of the same peptides.[xviii] Not being much of a bio-chemical reductionist myself, let alone a bio-chemist, I prefer to denominate this human capacity for self engagement by the name that scientific medicine first used to exclude it: “the imagination.”  Certainly, the imagination is a capacious if not nebulous concept whose history marks the trajectory of human thinking both about thinking and about “the human.” However, “the imagination” was precisely what late eighteenth-century scientists and natural philosophers discovered they needed to exclude in order to ground the possibility for establishing a deterministic causality with respect to human bodies. For, as Cornelius Castoriadis remarks: “The imagination is … in its essence rebellious against determinacy.”[xix] Thus, the imagination continues to offer a useful fulcrum for prizing apart the deterministic logic that underwrites our contemporary bio-medical understanding. As I will use it here, the imagination simply refers to the hylemorphic capacity of humans: i.e., our capacity to inform the matter that we are. The imagination  (in my imagination) thus specifies “the human” as a hybrid concept marking our corporeality and conceptuality as inextricably intertwined. In this regard, medicine itself constitutes an “imaginary” practice, albeit one that is also material and real. Indeed, as I will suggest below, it is by appropriating the imagination for its own projects and disavowing its significance for those whom it treats that bio-medicine comes to dominate the province of healing throughout the course of the nineteenth and twentieth centuries. 

In this undertaking, the placebo, as a derisive designation for treatments that are merely “pleasing” and therefore simply “imaginary,” actively polices the demarcation between mind and matter that scientific medicine used to define its turf. When the placebo gets refigured in the twentieth century, first to name the control elements that produce the “objectivity” of clinical testing, and then to refer to the unintended amelioration that these controls seem to regularly induce, it carries with it the disavowed effects of the imagination to which the placebo’s “pleasing” aspect appeals. By constituting the placebo effect as an (as yet) inexplicable healing consequence revealed by the very experimental apparatus that was designed to affirm determinant bio-chemical causality, contemporary bio-science can both evoke and efface the play of the imagination as it informs the materiality of humans.It is in this sense that I referred above to the placebo as a fetish for the imagination: the placebo covers over the absence where the material effects of the excised imagination continue to manifest themselves within the bio-medical apparatus. In either avowing or disavowing the placebo, in either appropriating or denying its effects, biomedicine simultaneously invokes and excludes the imagination as one of its most powerful resources for healing. Yet when medical rationality conjures the imagination as that which it must bracket in order to assure the efficacy of a drug or a treatment protocol, it rejects out of hand any results not induced by the material “cause” under consideration.  What bio-science (especially in its contemporary corporate forms) wants and needs, is to establish unilateral relations between material treatments and documented cures which it can then use both to demonstrate its practices and to market its products.  While this desire for monocausal explanation has undoubtedly contributed to the ameliorative effects to which bio-medicine has given rise, it also radically limits the domain of healing action and of healing agents. The possibility that the imagination of a person who suffers might play a curative role within the event of illness is a priori excluded from scientific medicine because it introduces a non-reducible variable which  de-centers bio-science’s self representation as the only legitimate agent of healing.  Thus, within scientific medicine, the “placebo effect” is bracketed not because it does not produce healing effects, but precisely  because it does; however, the effects the placebo produces are negatively attributed to the imagination and thus deemed without real interest.

In order to flesh out the troubling paradox that the placebo effect presents for contemporary bio-science, it is necessary to reflect on how and why “the imagination” came to be excluded from proper medicine.  Or even: how and why the exclusion of “the imagination” from medicine comes to define the kind of knowledge that constitutes the “property” of medicine.  As the historian and philosopher of science, Isabelle Stengers suggests in her brilliant essay "The Doctor and The Charlatan," it is precisely by abjuring “the imagination” that medical rationality captured the Western imagination in the first place.[xx]  Stengers takes the denunciation of the "charlatan" as an "inaugural scene" of scientific medicine and illustrates how by disqualifying the imagination as a therapeutically effective force, bio-science clears the epistemological ground for bio-medical detemininism. This disqualification in turn marks the threshold of bio-medicine's scientificity per se.  The reciprocal action of disqualification and (or as) qualification situates the knowledge claims of bio-medicine within the penumbra of "truth" in so far as it negates the material possibility for what we might call "imaginary transformation."  Yet it succeeds in doing so only to the extent that it itself brings such imaginary transformation to bear against the imagination in the first place.  Indeed, as Stengers argues elsewhere, the "power of fiction" is constitutive of science generally since "it is that against which science must differentiate itself, and that through which it defines-disqualifies everything that is not science."[xxi]

Medicine has existed as an authorized and authorizing profession since the Middle Ages.  However, in the late eighteenth century it sought to revalorize its superiority over and against other more heterodox or traditional healing practices by setting up shop in the domain of science (even as the understanding of what would make such a science "scientific" was still very far from clear).  In other words, by asserting a privileged relation to scientific rationality, medicine sought to solidify its authority to name and shape social reality over and against all other forms of healing; simultaneously it sought to institutionalize its right to regulate those who could be so authorized.  As numerous histories of science have demonstrated, the conditions under which any science could provide "true" knowledge about the material world were widely contested and negotiated throughout the seventeenth and eighteenth centuries.[xxii]  Yet, even as challenging as these questions of truth were for the physical sciences generally, the question of scientificity was especially vexing for the relatively belated domain of biology—first denominated as an epistemological field in 1800--which took such changeable entities as organisms for its provenance.[xxiii]   Needless to say, it was even more problematic for medicine which took the healing of the self reflexive human organism as its object.[xxiv]  In this emerging moment, when medicine was enthusiastically trying to hitch its wagon to science’s ascending star, any bodily transformations that could be attributed to the imagination rather than to demonstrable material causes provided an especially vexing impediment to the establishment of bio-scientific certainty and hence threatened the credibility of bio-medical superiority. 

Continued
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