Age is a question of mind over matter. If you don’t mind, it doesn’t matter.
—Satchel Paige, legendary pitcher in the Negro leagues and Major League Baseball
As the team surgeon for the Houston Rockets basketball team, Bruce Moseley performs a lot of knee surgeries on players. Arthroscopy is a common surgical procedure used to examine and treat knee joints. To perform these surgeries, Dr. Moseley inserts a small metal tube called an arthroscope into the knee and then uses it to repair damaged cartilage and remove loose bone fragments that cause pain. A million knee arthroscopies are performed each year in the United States at a cost of $5,000 each, making a total annual bill of $5 billion.
By observing that players with positive attitudes seemed to recover more quickly, Dr. Moseley got the idea that placebo arthroscopy might be almost as good as the real thing. So he found 180 patients who had such bad knee pain that even the best drugs had failed to work for more than six months. Many were in so much pain they had trouble getting out of their chairs. He gave half of them real arthroscopy and the other half placebo arthroscopy. Patients in the placebo arthroscopy group were given anesthetics and a small incision was made in their knees, but there was no arthroscope, no repairing of damaged cartilage, and no cleaning out of loose fragments of bone. To keep the patients ignorant about which group they were in, the doctors and nurses talked through a real procedure even if they were performing the placebo procedure.
Bruce Moseley and his team then monitored the patients, asking them how much pain they felt and measuring how far they could walk and how many stairs they could climb before their pain got in the way. After two years, even Bruce Moseley was surprised. The placebo was not almost as good as the real surgery—it was equally as good.
When I read Bruce Moseley’s study, I was surprised because I had never heard of placebo surgery. And in spite of my research, I was skeptical about how surgery could cure what appeared to be a purely local, mechanical problem. I even wondered whether the people in the trial would have recovered without any surgery (placebo surgery or real surgery). Like the POWs in Cochrane’s story in Chapter 1, perhaps Moseley’s patients were merely outstanding examples of how humans can get better without any treatment. However, this was not likely. The patients in the trial had not responded to even the best drugs for more than six months. So the sham surgery seemed to have done something rather dramatic to these patients.
My next reaction was that the placebo surgery might have worked for subjective psychological issues such as feeling better, but not for more objective, physical outcomes. But the patients in the placebo group were able to climb more stairs and walk farther than they were before, too. So the placebo surgery was effective for physical outcomes as well as psychological ones. I was still not convinced: How could a placebo fix a mechanical problem with the knee? So I thought maybe Moseley’s study was a fluke. It wasn’t. It turns out there have been other placebo surgery trials with comparable results.
Vertebroplasty is a fancy name for making a small cut in someone’s back, then injecting bone cement (a kind of glue) into a damaged vertebra. In 2003, 25,000 Americans underwent this procedure. The number of people getting vertebroplasties is closer to 100,000 a year now, and they cost $5,000 each. Close to $500 million dollars are spent on vertebroplasty every year in the United States alone.
Researchers from Australia took seventy-eight patients with spinal fractures. Half of them got the real surgery, while the other half got fake vertebroplasty. To perform the placebo surgery, surgeons cut the skin and tapped the bone but didn’t inject any cement. Patients didn’t know whether they were getting the real or the fake surgery. Patients who got the placebo procedure did as well as patients given the real procedure. In some ways the real vertebroplasty was worse, because patients who got it were more likely to need drugs. Not only that, the cement used to glue the fractured bone together often leaks, possibly causing more fractures, trouble controlling urination, and weakness in the legs.
Placebo arthroscopy and placebo vertebroplasty are not the only fake surgeries that work. Some of my colleagues at Oxford University recently researched more than fifty placebo-controlled trials of various surgical techniques and found that the placebo surgery was as good as the real surgery in more than half the trials.
If placebo surgery works for knee and back pain, this raises the question about whether we need the expensive and risky surgery (placebo or real) at all. In fact, many don’t. Two systematic reviews with 29 trials have found that much less invasive options, such as physiotherapy, are as good as back surgery. I have been offered both back and knee surgery and I am happy that I have refused both. When I injured my back rowing, a surgeon proposed to operate on me but I was scared of the risks and refused. Some activities like heavy squats or certain weightlifting exercises can still give me some back pain, but overall I have cured myself with yoga. Two years ago, I twisted my knee playing volleyball, and soon after (in spite of the pain), I ran a half-marathon. It hurt a lot during the run and the pain didn’t go away even after a few weeks of rest. I couldn’t bend it more than forty-five degrees, and walking more than a few minutes hurt, so I had a scan.
The doctors told me my meniscus was torn and I should get surgery. I thought it would be hypocritical to do the surgery since I was writing this book, so I chose physiotherapy instead. There is a lot of evidence that physiotherapy is great for reducing knee pain.
My knee is now almost completely better. I can almost bend it fully and I went for a three-hour run last week and it didn’t bother me. I am not saying I will never have surgery, but if there is a more conservative, cheaper, and less risky option, I’ll try that one first.
Placebo surgery is likely to work via more than one mechanism. First, placebo surgery activates systems that produce pain-relieving drugs like endorphins and dopamine. As for the placebo knee surgery, I suspect that the star status of Bruce Moseley himself might have played a role. He is quite a character. How would you feel if you entered the operating room to see the guy who’s on TV whenever you watch basketball?
One of the patients who had the placebo surgery was named Sylvester Colligan, who was seventy-six years old at the time. He was interviewed after they told him he had the placebo surgery. About Dr. Moseley he said: “I was very impressed with him, especially when I heard he was the team doctor with the [Houston] Rockets. . . . So, sure, I went ahead and signed up for this new thing he was doing. . . . The surgery was two years ago and the knee never has bothered me since. . . . It is just like my other knee now. I give a whole lot of credit to Dr. Moseley. Whenever I see him on the TV during a basketball game, I call the wife in and say, ‘Hey, there’s the doctor that fixed my knee!’”
International placebo expert Dan Moerman met Dr. Moseley and reports: “He is a very impressive man. He’s tall, strong, and athletic looking. He has a firm, friendly, and persuasive manner . . . he sure looks like a good surgeon to me, even though I’ve never seen him on TV, and I’m not much of a basketball fan.”
All this means that when Bruce Moseley treats you, you expect to get better. We will further explore how positive expectations can induce your body to produce its own painkillers in Chapter 8, and how doctors with a good bedside manner can have a healing effect in Chapter 10.
There is another explanation for how placebo surgery might work: it activates the body’s power of regeneration, known as the wound-healing cascade. All living organisms are very good at regenerating themselves when they get cut or injured. If you cut off an earthworm’s head, it completely grows back. You can’t grow a human head back if it gets chopped off, but your body can repair itself very well.
The wound-healing cascade is activated whenever you get a cut. The body does not know whether the cut is from a thorn that scrapes you or from a friendly surgeon’s knife. It simply starts healing in the region where damage has occurred, even if the damage was caused by a surgeon who was trying to help. It begins with blood clotting in the injured region to stop the bleeding. Then white blood cells phagocytose unwanted cells. This is a fancy way of saying they eat them. Next the body makes new blood vessels in the region so that it can send more nutrients and growth hormones to rebuild the damaged area. Finally, the wound is healed when new scar tissue and skin cover it.
Placebo back-pain surgery has an additional mechanism. When you get the placebo surgery, you are given a pretty hefty dose of local painkiller. This can cause your back pain to subside for some time. With less pain, you feel freer to move around, and the moving around might have a benefit (exercise reduces back pain).
Effective placebo surgery shows that more invasive and more expensive real surgery is less necessary than we think. It also suggests that positive beliefs about the outcome of a treatment can cure mechanical as well as psychological problems. I know a lot of people who have had knee and back surgery. Many of them needed to return for further surgeries, and they rarely accept that there might have been a better option.
For instance, when I told someone I met at a Christmas party who was going to go for his third knee surgery about the placebo effect, he said, “Maybe placebos work for psychological things like mild pain, but I can show you my knee X-ray, there is physical mechanical damage. Placebos can’t help that.” He may be correct, that the physical damage to his knee is much worse than the physical damage done to Bruce Moseley’s patients, but statistically the chances are that his problem was no more severe than Moseley’s patients. More important, his response implies two beliefs:
Both of these beliefs have some truth but are generally mistaken. The mind and body are intimately connected and the body’s different parts are connected to one another. Both of these false beliefs can be traced back to the French philosopher and mathematician René Descartes.
The idea that placebos can cure “psychological” things like pain and depression but not “physiological” ones like damaged knees only makes sense if we separate the psychological—the mind—from the physiological—the body. The idea that the mind and body are separate is quite new and was developed by Descartes. You may have heard this song as a child:
Row, row, row your boat
Gently down the stream
Merrily, merrily, merrily, merrily
Life is but a dream
As a child, I thought about it and wondered whether we were dreaming that we were alive. I asked my mother whether we were only dreaming, and she said she just knew she was not dreaming. I kept asking how she knew and never got a satisfactory answer. Kids are great philosophers, because they always ask why. Descartes used that same trick to investigate what he knew for sure and what he was not sure about—what he might be dreaming about.
After asking himself why a few dozen times, he became convinced that he couldn’t even be sure he had a body—he might be dreaming that he had a body. He could, however, be sure that he had a mind, because you need a mind to dream and think. That is when he said, “I think, therefore I am.” A consequence of Descartes’s inspiration about having a mind but not a body led him to separate the mind and body. The idea that the mind and body were separate was revolutionary at the time, because people at that time believed that minds, souls, or “vital forces” were part of the body. That is why before Descartes’s idea took hold, people didn’t see a contradiction in things such as faith healing and holy water, which allegedly cured many ailments.
Unfortunately for Descartes, his idea that the mind and body are separate does not stand up to common sense. If they could be separated, then:
The mind-body connection provides a basis for accepting how placebo surgery can improve “physical” symptoms. It shows how relaxing your body can relax your mind (and vice versa). And, as we will see in Chapter 8, positive thoughts can trigger your body to produce the endorphins and dopamine that make your body feel good.
To be fair to Descartes, he admitted that the mind and body interacted, but once he had separated them, he had trouble explaining adequately how they could interact. In spite of the fact that common sense tells us that the mind and body are intimately connected, we still continue to speak as though some things are “just psychological” and others are physical or mechanical (and not psychological). I am not sure why this is the case. I suspect one reason is that most societies have become secular, and science has done away with souls and other invisible things, so the only option is to see bodies as soulless machines.
Talking about machines, Descartes had another idea that continues to make it difficult for us to see how the mind can influence the body. He thought the body was a machine. If the body is a machine, it is natural to look at one part of the body, such as the knee, in isolation. If part of a machine is faulty, we fix it. There is no point worrying about the machine “as a whole,” let alone how a mind influences it.
Descartes was not entirely wrong to say that we are machines. Our heart is like a pump, our muscles and bones act like pulleys and levers, and even drugs seem to work on cells the way a minitool might work on a tiny machine. Treating the body like a machine has led to many advances in surgery and medicine. At a general level, however, your body is more than a machine.
You might try to describe someone by describing how tall they are, what color their skin and hair are, what their voice sounds like, and how beautiful their eyes, nose, lips, and legs are. This would be good, but it misses something about them as a whole person. For example (God forbid), what if the person you describe gets in an accident and has to have a finger amputated, and they need plastic surgery, which makes their nose smaller? Now they will look different. Yet in essence, they would still be the same person. There is something more to us than our parts.
If a part of a machine is broken, you can fix it and it does not affect the other parts too much. Not so with the body. In order to maintain what scientists call homeostasis (basically: balance), different systems need to work together. To survive, the body needs to maintain the right body temperature, breathing rate, and heart rate. So when the body temperature falls, blood vessels contract to preserve heat, shivering is induced to make muscles more active (and produce more heat), and you stop sweating. This makes the body temperature rise. If the body temperature gets too high, blood vessels get bigger to release more heat, and you sweat to cool off. All these systems—blood vessels dilating, sweat glands giving off fluid or not, and shivering—are connected, so when you affect one, you affect the other. Yet when we read about new discoveries in the media, we often hear things like “new drug targets cancer cells.” But you can almost never target just one kind of cell without affecting other cells and other systems.
In addition to being connected, the parts of the body are linked in often unknown ways. Take the example of unpredicted drug effects. In 2006, a drug called TGN1412 was first tested on six healthy volunteers who were paid £2,000 (about $2,500) each to participate in the trial. The first time that drugs are used with humans, scientists use tiny doses for safety reasons. In the first TGN1412 trial, the dose used in the humans was five hundred times lower than that found to be safe and effective in monkeys.
Yet within minutes of being given these very low doses, the white blood cells in the human volunteers disappeared. This led to catastrophic organ failure with the victims fighting for their lives, more than a month of hospitalization, and likely permanent damage to their immune systems that will leave them vulnerable to disease for the rest of their lives. One of the victims lost all his toes and the tips of all his fingers. Not only did the drug operate differently in animals than in humans (which is obvious to many people), but the organ failure was not predicted by scientists who had studied the drug for many years. In addition to activating the system they thought it would activate, the drug also acted on other parts with disastrous consequences. Different parts of the patients’ bodies were connected in ways that the scientists didn’t predict.
More rarely, drugs can have surprising positive effects. For example, sildenafil, originally developed to reduce chest pain, didn’t have much of an effect for this in trials. However, researchers at the drug company Pfizer, who owned it, noticed that many of the middle-aged men in the trial were asking for more because it improved their sex lives dramatically. The drug was subsequently marketed as Viagra and became a huge commercial success. Again, the reason for the surprising effect was that Viagra activated an unsuspected mechanism in men’s reproductive organs.
Besides being hopelessly interconnected, two things tie your body as a whole together and make it difficult for the health of an individual part to be viewed in isolation. These two things are life and consciousness. The fact that your body is alive cannot be explained by looking at the atoms and molecules or any other parts that make up your body. Your body is composed of oxygen (65 percent), carbon (18 percent), hydrogen (10 percent), nitrogen (3 percent), calcium (1.5 percent), phosphorus (1 percent), potassium (0.5 percent), and 1 percent other stuff, such as boron, chromium, cobalt, copper, fluorine, iodine, and iron.
You can buy these chemicals for a few dollars at a chemical factory. What is it about the arrangement of these chemicals that makes you alive? What it means to be alive has perplexed scientists and philosophers for centuries, and there is no straightforward answer. Yet we cannot talk about the body or its parts without mentioning life, which ties everything together.
Consciousness also ties our entire bodies together. Live humans, and probably many other animals, are conscious. If you are reading these words and you are aware that you are reading them, then you are conscious. When you taste food, you are conscious. If you get knocked out or you are in a coma you are still alive, but you are not really aware and something central is missing from your life. Consciousness is fundamental to the idea of being alive. Scientists and philosophers have been chasing their tails for centuries trying to discover what and where it is. They have looked everywhere in the body and can’t find it. They can find things in our brains that are correlated with our experience (for example, a part of the brain lights up when we see a dog), but they have not explained our experience of seeing a dog.
Not wanting to invoke souls or vital forces, scientists came up with emergent properties to explain life and consciousness. A good example of an emergent property is water. Water is made up of hydrogen and oxygen atoms. Separately, at room temperature both oxygen and hydrogen are highly flammable gases. Water is composed of oxygen and hydrogen but is a liquid at room temperature and is pretty much the opposite of flammable. You cannot predict what water is like no matter how hard you stare at oxygen and hydrogen atoms. The wetness of water emerges out of the combination of hydrogen and oxygen atoms.
Consciousness and life can also be described as emergent properties. According to the emergent-property point of view, life emerges from the body’s organization of molecules, cells, and organs. Scientists and philosophers say that emergence is scientific and not mysterious in the way souls and vital forces are. The emergence story makes sense, but it is unclear how using the word emergence helps explain the nature of life. Leading experts have been trying for decades to define why emergence is more scientific than older concepts like souls and vital forces. It is fair to say that the jury is still out regarding the extent to which they have succeeded.
I don’t really care if people call life and consciousness emergent properties or something else. The fact is that there is something about your whole body that makes it alive, that connects all your body parts together. And—what is more relevant to understanding placebo surgery—where you direct your consciousness (such as toward positive thoughts) can affect your body.
Understanding that your body is more than just a machine, and that your mind and body are connected, makes it much easier to understand how placebo surgery works. The reason people think that surgery is the best treatment for “purely mechanical” knee or back problems is that they view the knee or vertebra as isolated parts of the body. The wound-healing cascade shows how the different parts of the body can reorganize themselves to compensate for, and even heal, damage done to the knee or back.
Placebo surgery can also work because we expect it to work: our minds can influence our bodies. As we saw in Chapter 6, the mind can influence the immune system, and as we will see in Chapter 8, the mind can induce the body to produce its own painkillers. This doesn’t mean that thinking positive thoughts will immediately cure all the diseases in the world. It does not mean our cars can run on Earl Grey tea if only we wish it deeply enough. But as Dan Moerman said in the quote at the beginning of this book, “People are not machines, and we shouldn’t treat them as such.”
Unless you are an extreme case, discuss with your doctor the possibility of conservative management before opting for back, hip, or knee surgery. Systematic reviews have shown that surgery is rarely better than conservative management for these problems (including many types of fractures). Conservative management means doing physiotherapy and other lifestyle interventions such as exercise and improving diet. Go back to the dialogue at the end of Chapter 2 (here) and have an open, two-way conversation with your doctor.
The relaxation exercises in this book and (appropriate) yoga have also been shown to help with back, knee, and hip problems. There are two big advantages of conservative therapy over surgery. First, it does not have the side effects of surgery. A quarter of patients undergoing surgery experience side effects, including fractures, heart disease, trouble breathing, blood clots, stroke, additional operations, and even death. Second, conservative management is much cheaper, which is better for your pocket. Even if you live in a country with a national health service, you still save money, because it will affect taxes.
This exercise is easy and fun. To do it, you will have to read through it once and then try it. Whether you are standing up or sitting down, hunch your shoulders forward and look down at the ground. Stay in that position and imagine a scale from 1 to 10, in which 10 means “never felt better” and 1 means “never felt worse.” What number would you give yourself on that scale? Remember that number. Now sit up tall with your shoulders back and chest sticking out. Even if you have to fake it, put a little smile on your face. Thinking of the same scale, where 1 means you feel terrible and 10 means you have never felt better—now where do you rank yourself?
Remember the number. Is it higher than the number you gave yourself when you hunched over? By far the vast majority of people find that they feel quite a bit better. Even feeling a few points higher means that simple exercise had the same effect as some drugs. So the next time you need a little boost, just stand or sit up straight, and smile (even if you have to fake it). Now think . . . could a machine do that and feel the same way?
Here is a mistaken line of reasoning that I sometimes hear:
This line of reasoning is wrong. It is true that thoughts can influence your health—however, so does your body. I was born with jaundice and that had nothing to do with my thoughts. Simply because the body and mind are connected, it does not mean that the mind controls everything about the body. The body is a key player on the team, too. So it is wrong to say that if you are sick, it is only because you are thinking the wrong thoughts.
Also, just because thinking positive thoughts will make us feel better, it doesn’t mean that doing so is easy. In the same way that people’s bodies are different, so are their thought patterns. Some people, like Khamis Elessi and Alice Herz-Sommers (mentioned in Chapter 6), are naturally more optimistic than others. I would say I have average optimism and sometimes I find it difficult to be positive, but my negative thoughts rarely lead to depression or failure to get on with life. Other people I know are negative no matter what. For whatever reason—genetics, upbringing, and other experiences—we have developed our own thought patterns, and it is as hard to change these as making our biceps bigger. It is easiest to understand the difficulty in altering our thought patterns if we acknowledge the reality and importance of the mind.
There is a bigger reason why it makes no sense to believe that your health is your fault. When you blame someone, you are not making them happy. As we are all connected to other people (more about this in Part IV of this book), making someone else unhappy will have an adverse effect on us.
Since you are someone, you also should not blame yourself if you find it difficult to modify your thoughts and habits. Avoid the blame game.