Review of Haller: Shadow Medicine

Review of Haller: Shadow Medicine
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  [ e-1 ] WEB CONTENT ONLY  Kennedy Institute of Ethics Journal V   ol. 29, No. 2, E-1–E-23 © 2019 by Johns Hopkins University Press Book Reviews  John S. Haller Jr., Shadow Medicine: The Placebo in Conventional and Alternative Therapies , Columbia University Press, 2014Placebos are much discussed in both the medical and philosophy o medicine literatures. Once narrowly dened as inert “sugar pills,” (Holman 2015), they now are now most oten taken to be “treatments that appear similar to experimental treatments, but that lack their characteristic components” (Howick et. al. 2013). In addition to their use in the control groups o many clinical trials, placebos are also now widely recognized by medical practitioners to be powerul therapies in themselves, oten outperorming conventional drug therapies in these studies.Given this, I nd Haller’s book, which is divided into six chapters, “Evidence Based Medicine,” “Postmodernist Medicine,” “The Powerul Placebo,” “Politics o Healing,” “Complementary and Alternative Medicine’s Challenge,” “Reassessment,” an introduction and an appendix, to be interesting, yet dicult to interpret with regard to his main thesis. As ar as I can tell, Haller’s central claim is that, given the currently available evidence, we should understand complementary and alternative medicine (CAM) treatments to be placebos rather than actual treatments. In Haller’s view, CAM is an “opinion-based system,” which is “not unlike aith healing,” (82) and is concerned not with mechanisms o action, but rather solely with patient outcomes. CAM is thus contrasted in the book with evidence based medicine (EBM), which Haller argues relies on scientic evidence (in particular the randomized controlled trial, or RCT) rather than personal belie and is concerned not just with whether or not a treatment works, but also with how it does. On his view, EBM is thus “rationalist” while CAM is “empiricist.”This characterization o EBM vs. CAM, while central is the book, is problematic. In contrast to what Haller asserts, it is a hallmark o EBM that it is explicitly not concerned with mechanistic evidence. That is exactly the power (or the pitall) o the much celebrated RCT. RCTs are designed to tell us whether or not a treatment works, not how it does (Kennedy and Malanowski 2018). On the EBM paradigm, mechanistic reasoning is considered to be a ar inerior orm o evidence to randomized trials, and in some cases is not even considered to be evidence at all. It  KENNEDY INSTITUTE OF ETHICS JOURNAL • MARCH 2019 [ e-2 ] WEB CONTENT ONLY seems air to say, then, that both EBM and CAM are primarily concerned with therapeutic eectiveness and patient outcomes, rather than with mechanisms o action. (As an aside, this should mean that, contra to what many CAM practitioners argue, the RCT should in act be a reliable method or testing the eectiveness o CAM therapies. On the other hand, this means that EBM practitioners cannot dismiss CAM treatments as “sham,” merely on the basis o the lack o a mechanistic explanation that describes how such therapies, such as homeopathy. By its own lights, EBM argues that mechanisms either don’t matter or don’t matter much. Instead, what matters in medicine is whether or a not a treatment is a) sae and b) eective. The same, it seems, can be said o CAM, but this important similarity between EBM and CAM seems to escape Haller’s notice.Further, in some parts o the book, Haller seems to contrast “placebos” with actual treatments, while in other parts, he seems to acknowledge that placebos are treatments. On the one hand, he claims that the placebo is “a product o postmodernist medicine,” which he describes a reaction to and against reductionist scientic medicine, because it interjects “subjectivity, uncertainty and ambiguity into the clinical encounter” (63). This seems to suggest that the way placebos work cannot (or at least should not) be understood scientically. On the other hand, however, Haller argues that placebos are “real,” in that they “aect patients physiologically as well as psychologically. They alter blood pressure, heart, respiratory rate, and even body temperature” (73).This tension, between the old view o placebos as inert and the newer view that acknowledges that they can be eicacious (and testable) treatments in themselves is certainly an issue well worth exploring – and Haller should be commended or doing so. The book could be much clearer, however, in exactly what it is arguing. Is the claim that placebos can and should be used in medicine (broadly construed so as to include both EBM and CAM)? Or is it that CAM shouldn’t be understood as medicine, properly construed, because it relies on a “placebo eect” that cannot be scientically measured or veried? Or is it that “Western science needs to advance beyond the current reductionist model to some blending o the subjective and social aspects o healing that includes the placebo?” (157). Should or should not placebos be considered as potentially ecacious treatments in either CAM or EBM? And is this something that can be objectively decided? These questions, while hovering under the surace in the book are neither clearly explicated nor adequately answered.  BOOK REVIEWS — WEB CONTENT ONLY [ e-3 ] WEB CONTENT ONLY The book does do a good job o giving a thorough history o the evidence based medicine movement and the advent and subsequent widespread acceptance o the randomized controlled trial (in the rst chapter), as well as the history o homeopathy (in chapter 5). Readers interested in these topics will nd a helpul resource here. For a more complete philosophical and medical exploration o placebos, however, they will likely need to look elsewhere. Ashley Graham KennedyFlorida Atlantic University Boca Raton, FL  REFERENCES Holman, Bennett. 2015. “Why Sugar Pills are not Placebos” Philosophy o Sci-ence , 82:1330–1343.Howick J, Friedemann C, Tsakok M, Watson R, Tsakok T, et al. 2013. “Are Treatments More Eective than Placebos? A Systematic Review and Meta-Analysis.” PLoS ONE  8 (5): e62599Kennedy, Ashley and Sarah Malanowski. 2010. “Mechanistic Reasoning and Inormed Consent.” Bioethics 33 (1): 162–168. Victoria Pitts-Taylor, The Brain’s Body: Neuroscience and Corporeal Politics , Duke University Press, 2016 The brain matters . Says the opening line rom Victoria Pitts-Taylor’s The Brain’s Body: Neuroscience and Corporeal Politics. On the ace o it, the human brain matters inasmuch as it is the body’s central inormation processing organ; the CEO that presides over many o our executive bodily unctions. But the brain matters beyond the ways in which it has biologically evolved and currently processes inormation. The brain also matters in social thought, as neuroscientic research has historically inormed widespread perceptions o certain bodies and persons at the social and institutional level. Moreover, the brain is embodied, and bodies accrue social and political meanings beyond what they represent at the level o scientic interest. Pitts-Taylor takes this interplay between science and culture as her starting point, and she investigates the entanglement o brains and bodies with cultures and ideologies (1).  KENNEDY INSTITUTE OF ETHICS JOURNAL • MARCH 2019 [ e-4 ] WEB CONTENT ONLY The project o Pitts-Taylor’s book can be broadly situated at the crossroads o eminist theory, neuroscience, philosophy o biology, social epistemology, and queer and disability theory. In the introduction, she limns the broad historical architecture o this varied, interdisciplinary locale. For much o 20th century thought, the brain and the mind had been separately conceptualized as objects o philosophical and scientic inquiry. The brain belonged to the body, or the most part, while the mind was conceived as an epiphenomenal happening o its own. Toward the end o the century, however, such conceptual distinctions began to seriously weaken, as the boundaries between philosophy, cognitive science, and neuroscience started to erode. Soon, the brain and the mind coalesced into a biological whole, and a new conception o the mind as both embodied and deeply social came into prominence among some researchers in the neurobiological sciences. At this juncture, the mind/brain, with its deeply social prole and underpinnings, was no longer regarded as biologically xed. Instead, the brain was now understood as “the product o embodied experience,” as “the oundation or (and refected in) social structures,” and as “subject to intervention and transormation.” (5) The Brain’s Body  ollows in this lineage o naturalistic questioning into, among other things, the mindedness o the body, the bio-materiality o cognition, and the situatedness o cognizing bodies in material cultures. In the spirit o critical rebelliousness, however, Pitts-Taylor’s book turns this lineage on itsel, animating its critique and commentary by calling the cultural situatedness o this tradition itsel into question. I the brain, qua  the object o study, is plastic and can be socially infuenced, should we not, qua theorists o the embodied brain, also heed and problematize the ways that such infuences congure into our theorizing about the brain and the body? Pitts-Taylor thinks that we should! But this means that our theorizing about the brain is itsel deeply plastic and impressionable, and thus open to the infuence o social and ideological structures. Pitts-Taylor’s book, in a nutshell, is concerned with this concentric interplay o brains, bodies, and power structures. In a view that the book persuasively argues or, this interdependence is not merely symbolic, but also extends into the ways in which material structures are congured, including the literal structure o the brain. As such, and as the subtitle o the work suggests, “the book is concerned with the corporeal politics o the brain and the neurobiological body”(5) wherein the interplay o discourse and ideology maniests not merely through symbolisms and at the level o representations, but also in the corporeality o the world around us.  BOOK REVIEWS — WEB CONTENT ONLY [ e-5 ] WEB CONTENT ONLY Along these lines, Chapter 1 oers a discussion o the phenomenon o plasticity. The concept o neural plasticity, which reers to the ability o our brains to change and be changed, captures an exciting reprieve rom the orthodoxy o neurodeterminism and biological reductionism. But, with the advancement o various orms o biotechnology, plasticity research also now holds potential or dierent modes o biogovernance and pharmaceutical intervention into contemporary lie. 1 As such, plasticity is a condition that has to be reckoned with, especially at this late stage o capitalism, where any possibility or modication and transormation is oten concomitantly also regarded as a possibility or commercial control. For Pitts-Taylor, conronting such possibilities brings two questions to the ore.First, is it possible to extract the neural essence o plasticity rom its representations in everyday and scientic discourse? For fat-ooted social constructionists, this is an impossible task, since the world is nothing but a concatenation o representational acts, and such acts are ideologically infected through and through. 2 As such, searching or true objectivity, somewhere out there in the really real world, is undamentally misguided since ‘objectivity’ is merely a conceptual device that we employ in the service o making sense o our chaotic experiences. This is unconvincing or Pitts-Taylor, and rightly so, because such accounts neglect an important question about how meanings are materialized into matter, or “how they literally modiy brains and body-subjects, and, conversely, how they are touched by what they represent.” (20) It is undeniably true that our concepts have meaning insoar as we  attribute meanings to them. But we are also materially embedded beings, and concept use takes place on this material terrain, populated with things, people, relationships, etc. In other words, our concepts draw on this materiality and in turn shape it. As theorists o the mind and the world, we thereore have to be alert to this interplay and interaction, and the progressive and oppressive possibilities that it entails.Second, what is the relationship between plasticity and agency? In what sense, asks Pitts-Taylor, is the plastic brain a work, and to whose agency does this work belong? Popular science tells us that the potential o plasticity truly belongs to us; that we are masters o our own neural domain, as it were. 3  But as culturally situated agents, many o our actions bear the imprint o cultural infuences. The plastic brain is thus no exception to such orms o cultural inscription. But given that cultures are repositories o social and political meanings, this means that the
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