The Folly of Fools (13 page)

What such work does reveal is that a sizable minority of people do
not
show a placebo effect, while others enjoy strong self-induced effects. This is consistent with what we know about hypnosis, as well as the ability to destroy memory of nonsense material. Presumably this variation is positively associated with the ability to be manipulated by others (indeed, all three examples above involve third-party effects). This suggests that an ability to self-deceive for positive effect is vulnerable to parasitism by others, allowing them to manipulate your suggestibility to their own benefit.

The following effects are very pronounced and demonstrate a clear connection between cost and perceived benefit. The placebo effect is stronger

• the larger the pill,

• the more expensive it is,

• when given in capsule form instead of a pill,

• the more invasive the procedure (injection better than pill, sham surgery is good),

• the more the patient is active (rubbing in the medicine),

• the more it has side effects, and

• the more the “doctor” looks like one (white lab coat with stethoscope).

The color of pills affects their effectiveness in different situations: white for pain (through association with aspirin?); red, orange, and yellow for stimulation; and blue and green for tranquilizers. Indeed, blue placebos can increase sleep via the blueness alone with probable immediate immune benefits (Chapter 6).

The general rules of the placebo effect are consistent with cognitive dissonance theory (Chapter 7)—the more a person commits to a position, the more he or she needs to rationalize the commitment, and greater rationalization apparently produces greater positive effects. Surgery offers repeated examples of the placebo effect. One of the great classics is the case of angina (heart pain) treated surgically in the United States in the 1960s by a minor chest operation in which two arteries near the heart were fused to (allegedly) increase blood flow to the heart, thereby reducing pain. It did the trick—pain was reduced, patients were happy, and so were the surgeons. Then some scientists did a nice study. They subjected a series of people to the same operation, opening the chest and cutting near the arteries, but they did not join any together. Everyone was sewn up the same way and nobody knew who had received which “operation” when later effects were evaluated. The beneficial effects were identical to those of the original operation. In other words, the entire effect seems to be that of a placebo. The joining of the two arteries had nothing to do with any beneficial effect.

Surgery appears to be unusually prone to placebo effects—presumably because of the great cost and the apparent massing of group support. In any case, some interventions are dubious in advance and with potential for future complications—to be corrected by further surgery—for example, think of Michael Jackson’s face. So there are built-in incentives for an entire subdiscipline to develop in unhealthy ways. Remunerectomies, for example, are performed solely to remove a patient’s wallet. Consider arthroscopic surgery, meant to correct defects in the knee, often due to osteoarthritis. A small study suggested that sham operations—with all the features of real ones—produced virtually the same benefits as the actual operations, suggesting that these were mainly beneficial as placebos. The actual operations were associated with greater maximum pain than the placebos, presumably because they were more invasive, but for overall level of pain and other measures, the placebo and surgery produced remarkably similar effects.

For effects on pain, the placebo has been studied in some detail, and there is no question that in some individuals, the mere belief that a pain reliever has been received is sufficient to induce the production of endorphins that, in turn, reduce the sensation of pain. That is, what the brain expects to happen in the near future affects its physiological state. It anticipates, and you can gain the benefit of that anticipation. The tendency of Alzheimer’s patients not to experience placebo effects may be related to their inability to anticipate the future.

Expectancy can create strong placebo effects through a mixture of past experiences of genuine medical effects and placebos. As one author has put it:

The medical treatment that people receive can be likened to conditioning trials. The doctor’s white coat, the voice of a caring person, the smell of a hospital or a practice, the prick of a syringe or the swallowing of a pill have all acquired a specific meaning through previous experience, leading to an expectation of pain relief.

Depression seems especially sensitive to the placebo effect. Numerous studies have shown that genuine antidepressants account for about 25 percent of the improvement, while the placebo effect accounts for the remaining 75 percent. Believing you are getting something to help you is more than half the battle. After all, depression is marked by hopelessness, and placebos offer nothing if not hope. I always think about this when I am being given an antidepressant. I am told not to wait for an effect for at least three or four weeks—“it needs to build up.” In other words, expect no direct test of utility anytime soon, and the usual rule of regression to the mean—or, things get better after they have gotten worse—will give you all the evidence you later need. In the meantime, get with the program! The most recent meta-analysis (2010) reveals a striking (and very welcome) fact. Placebos work as well as antidepressants for mild depression, but for severe depression, there is a sharp bifurcation: real medicine shows strong benefits and placebos almost none. This, as we have noted, is a characteristic feature of self-deception directed toward others: a modest amount works, but a great deal fails to impress.

The ability to produce autostimulatory effects is nicely illustrated by work on female sexuality. Women who appear to be sexually dysfunctional in failing to respond orgasmically can be induced to greater arousal by giving them false feedback on the blood flow to their pelvis (a correlate of arousal) to sexual stimuli. They appear to be talking themselves into greater arousal, somewhat like the sight of a man’s own erection may increase his sexual desire.

There is no doubt that placebo effects operate in athletics as well. Trials have shown that cyclists respond positively to word that they have been given caffeine (without getting any) about half as well as to the caffeine itself (along with word they are getting it). Merely telling the cyclists they are getting a heavier dose of caffeine produces a stronger positive athletic response. Even that cliché of working out—no pain, no gain—has a built-in placebo effect.

One can even induce a placebo effect out of a placebo effect. That is, you can tell someone with irritable bowel syndrome that he or she will now receive a placebo—an inert chemical with no medicine in it—but then tell the person that the placebo effect is powerful, often involuntary, helped by a positive attitude, and finally, that taking the pills faithfully is critical. With this much helpful verbiage, it is not surprising that a placebo identified as such still produces benefits.

The analogy with religion is strong and tempting. Both involve strong belief. Both involve a series of conditioned associations, including common doctor or pastoral elements. And, indeed, until very recently (up to about five thousand years), medicine and religion were one and the same. You can easily imagine that regular religious attendance (especially if the music is good!) would intensify placebo and other immune benefits, just as regular visits to a caring and sensible doctor or adviser might.

A striking feature of placebo effects is that they are highly variable across a population. Typically roughly one-third show very strong effects, perhaps one-third moderate, and one-third none. This is an example of what we have emphasized repeatedly, that the deceit and self-deception system must be an evolving one, with important genetic variation for forms and degree of self-deception. We do not know how much of the variation just mentioned is genetic, but recent work shows that people with depressive disorders differ in the degree to which they show a placebo effect based on particular genes.

What else correlates with a tendency to show a placebo effect? For one thing, suggestibility, as in ease of being hypnotized, is a trait that also shows high variability, some people being highly resistant and others easily manipulated. It should hardly surprise us that ease of being hypnotized and the placebo reaction should co-vary strongly and positively. Each is a kind of self-deception requiring a third party, a hypnotist or “doctor.” When people are divided into those who are easily hypnotized versus those who are not, then hypnotizing the susceptible to concentrate only on the color in which words are printed in the Stroop test (recognizing words denoting color that are written in different colors), causes them to show no interference from the words themselves. But people who are not susceptible show no improvement on the Stroop test. This, then, is a benefit from ease of being hypnotized: greater ability to concentrate or tolerate cognitive load.

We began this chapter with the illusion of conscious control. We then moved successively into deeper and subtler forms of external control—imposed self-deception in general, torture with its disassociations, false accusations of others and of self, the placebo effect, and hypnosis. It would now be valuable to tie these kinds of conflicts into our two major social relationships: the family (Chapter 4) and the two sexes (Chapter 5). When do we impose self-deceptions on family members and on sexual partners, and when and how are these imposed on us?

CHAPTER 4

Self-Deception in the Family—and the Split Self

W
e usually begin our lives—the first twenty years, at least—embedded in a family, typically one or both parents and one or more siblings. This is often part of a larger extended family including grandparents, uncles, cousins, and so on. The key to the biology of all this is genetic relatedness (r). That is, family members are all related to one another in the sense that there is a chance that any given gene in any one individual has an identical copy in another by direct descent from a common ancestor. A typical gene in a parent is found in its offspring half the time (hence r to offspring = ½), while a typical gene in the offspring is also found in either parent half of the time. Siblings are related by ½ but half-siblings by only ¼ and so on. This leads to “Hamilton’s rule,” which states that the benefit of an altruistic act toward a relative times the relevant degree of relatedness must be greater than the cost suffered by the altruist in order for selection to favor the altruism. For example, if you are helping your half-sister, then (other things being equal) the benefit to her had better be greater than four times the cost to you. Likewise, selection will oppose a selfish act that harms her four times more than it benefits you. In sum, degrees of relatedness in families are high—which tends to induce investment and restrict conflict—but degrees of relatedness are far from unitary (r = 1) so that conflict is also expected between the actors. For our purposes, the key is that relatedness adds an extra dimension and logic to the kinds of deception and self-deception that will evolve.

Parents can pretend to base their actions on shared relatedness to the child (parental investment) when, in fact, it is based on the unrelated part (parental exploitation). They may be unconscious of this bias. In turn, offspring may pretend greater need in order to induce more parental investment than is optimal for the parent, and they may be more effective when they believe it themselves. And so on. Relatedness in fact leads to a series of ramifying complexities where deceit and self-deception are concerned. These have to do with misrepresentation, manipulation, and internal bifurcation. Let us look at each in turn.

Since an individual is selected to act both altruistically and selfishly toward family members, there are chances for misrepresentations regarding motivation and orientation that are deeper than those occurring toward more distantly related people. For example, there is no presumption that a person with a low r to you is programmed to act in your self-interest, but that is precisely the presumption with related individuals—and the more so the more closely they are related to you. So your relatives can pretend an interest in you that is plausible on its face, even if their real motivation is completely manipulative. A relative can also lay a claim to you. Aren’t I related to you by one-fourth, so if you are messing up in life, aren’t you messing with my quarter interest in it? Get yourself together for
both
our sakes.

Or consider the following. Although one is selected to invest parental care in one’s offspring, one is not selected to give as much as requested, or always to give anything at all. Hence, deeper—and, probably often, more painful—misrepresentations are possible between close relatives. Are you investing in a child or exploiting it? Do you love the child or not? Do you have in mind a separate self-interest in the child that you are willing to support or is the child entirely conceived as instrumental to your larger projects? It makes a whale of a difference to the offspring which of these is true, and there is plenty of scope for deceit and self-deception on the part of the parent, as well as of the offspring.