Bad Science by Ben Goldacre Page A

although interestingly, perhaps not without collateral damage, and it must be done delicately; assertively and authoritatively giving someone access to the sick role can also reinforce destructive illness beliefs and behaviors, unnecessarily medicalize symptoms like aching muscles (which for many people are everyday occurrences), and militate against people’s getting on with life and getting better. It’s a very tricky area.
    I could go on. In fact, there has been a huge amount of research into the value of a good therapeutic relationship, and the general finding is that doctors who adopt a warm, friendly, and reassuring manner are more effective than those who keep consultations formal and do not offer reassurance. In the real world, there are structural cultural changes that make it harder and harder for a medical doctor to maximize the therapeutic benefit of a consultation. First, there is the pressure on time; a doctor can’t do much in a six-minute appointment.
    But more than these practical restrictions, there have also been structural changes in the ethical presumptions made by the medical profession, which make reassurance an increasingly outré business. A modern medic would struggle to find a form of words that would permit her to hand out a placebo, for example, and this is because of the difficulty in resolving two very different ethical principles: one is our obligation to heal our patients as effectively as we can; the other is our obligation not to tell them lies. In many cases the prohibition on reassurance and smoothing over worrying facts has been formalized, as the doctor and philosopher Raymond Tallis recently wrote, beyond what might be considered proportionate: “The drive to keep patients fully informed has led to exponential increases in the formal requirements for consent that only serve to confuse and frighten patients while delaying their access to needed medical attention.”
    I don’t want to suggest for one moment that historically this was the wrong call. Surveys show that patients want their doctors to tell them the truth about diagnoses and treatments.
    What is odd, perhaps, is how the primacy of patient autonomy and informed consent over efficacy, which is what we’re talking about here, was presumed but not actively discussed within the medical profession. Although the authoritative and paternalistic reassurance of the Victorian doctor who “blinds with science” is a thing of the past in medicine, the success of the alternative therapy movement—practitioners mislead, mystify, and blind their patients with sciencey-sounding “authoritative” explanations, like the most patronizing Victorian doctor imaginable—suggests that there may still be a market for that kind of approach.
    About a hundred years ago, these ethical issues were carefully documented by a thoughtful native Canadian Indian called Quesalid. Quesalid was a skeptic. He thought shamanism was bunk, that it worked only through belief, and he went undercover to investigate this idea. He found a shaman who was willing to take him on, and he learned all the tricks of the trade, including the classic performance piece in which the healer hides a tuft of down in the corner of his mouth and then, sucking and heaving, right at the peak of his healing ritual, brings it up, covered in blood from where he has discreetly bitten his lip, and solemnly presents it to the onlookers as a pathological specimen, extracted from the body of the afflicted patient.
    Quesalid had proof of the fakery, he knew the trick as an insider and was all set to expose those who carried it out; but as part of his training he had to do a bit of clinical work, and he was summoned by a family “who had dreamed of him as their saviour” to see a patient in distress. He did the trick with the tuft and was appalled, humbled, and amazed to find that his patient got better.
    Although he continued to maintain a healthy skepticism about most of his colleagues,