Letters to the Editor:

LETTERS TO THE EDITOR: Dear Sir: Professor Leon Eisenberg, in his William S. Paley lecture, published in this journal [1], argues for the inevitable role of the subjective in medicine. Agreeing with the general tenor of his opinions, I nevertheless believe that some of the author's arguments and their philosophical underpinnings should not go unchallenged . Eisenberg pleads for proper appreciation and understanding of "therapeutic response" or "placebo effect" which, he believes, has suffered defamation at the hands of the proponents of objective or scientific medicine, rendering a disservice to patients and the field itself. Yet one can plausibly claim that the beginnings of scientific medicine are coeval with attempts to better the placebo. The phrase "no better dian placebo" does not imply unawareness or contempt for the value ofthe therapeutic effect but frequently is meant as a declaration ofstriving for grounds loftier than those occupied by a shaman or witch doctor. The very idea of a properly planned and executed clinical trial is an attempt to evaluate a placebo versus a remedy with superior claims and thus certainly accounts for the inherently present placebo effect. To say that the placebo response "is no less real" than drug action only obscures the issue; incantation is as real as the administration of penicillin, but the results in the case of a patient with pneumoccocal pneumonia are vastly different. To say, as Eisenberg does, that "therapeutic effect is embedded in every therapeutic transaction" is to lump the importance of the effect in a case of, say, conversion hysteria, with the importance ofthe same in septic shock—making the quotation above empty ofcontent. Practicing the hairsplitter's trade, one can suggest that "hard" pathology (disease -rich) cases are mostly therapeutic effect poor, while "soft" pathology (illness -rich) cases are rich in therapeutic effect. Eisenberg uses an example ofcommon outpatient viral fever as an illustration of how frequently we engage in meaning-creating rituals rather than in the exercise ofrigorous applied biology; after all, we do not pursue appropriate viral studies in the great majority ofcases but still diagnose "viral infection." On closer examination, though, one sees that there is more here than meets the eye; before the virus is diagnosed, the physician engages in objective procedures of ruling out other entities, rigorous examination is performed, some pertinent studies are done. Thus, what is apparendy subjective could well be grounded in the verifiable or the objective. Permission to reprint a letter printed in this section may be obtained only from the author. Perspectives in Biology and Medicine, 28, 1 ¦ Autumn 1984 \ 167 The author uses an example of the great variability of tonsillectomy rates in various areas of New England, shown in studies ofWennberg, to argue his case. This suggests that Eisenberg believes that medical objectivity should entail uniformity or near uniformity of the therapeutic mode over and above the presumed objectivity of facts on which the intervention is based. But this is asking too much; the understanding of nuclear fission, as we all know too well, does not predetermine its social use. Medical intervention, even when based on the best of scientific grounds, will not achieve uniformity ofresult—like any other intervention in the sphere of complex human society. The author rejects total relativism (i.e., a view that considers disease to be a purely social and transactional construct) but explicitly espouses medical historicism (i.e., necessary awareness of our dependence on the changeable in timeinterpretive paradigms). Popular as this Kuhnsian view may be, it does not supersede neo-Platonistic, Tnomistic, or Popperian views of science. This could suggest, but notjustify, the reasons for omission ofepistemology from the medical curriculum. It always struck me that historicists, all too ready to consign our most cherished moral and epistemic axioms to vagaries of time, would claim a supratemporal exception toward their axiom "all views and opinions are historically conditioned." An impeccably performed study (e.g. Norwegian timolol study, hepatitis vaccine studies of Szmuness et al.) may be superseded or become irrelevant by the invention of a better drug or the disappearance ofa disease, but it will remain a valid objective achievement—as Newtonian physics is for a great range of phenomena . With stringent enough criteria...