Born Liars (20 page)

Our own health is bound up with our relationships to other people, particularly those who seek to cure us. Much depends on the signals the physician sends, consciously or unconsciously, about his confidence in the treatment; in the phrase of the medical anthropologist Daniel Moerman, the physician's demeanour seems to ‘activate the medication'. Medical researchers who carried out a historical review of the literature on the treatment of angina found that drugs that worked in the 1940s and 1950s dramatically decreased in effectiveness in the 1960s. This change was hard to explain in biochemical terms: the drugs hadn't changed, and nor had the human body. The authors of the study concluded that it hinged on the rise of the double-blind trial, which revealed to the medical profession that some of the drugs they had been using worked no better than placebos. In other words, patients who received the medication from doctors who truly believed that it was powerful were much more likely to get better than those who received it from doctors who had their doubts.
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It's not just the doctor himself who affects our confidence or inspires our imaginations, it's everything that surrounds him; the cultural symbols of health and healing. The psychologist Irving Kirsch enrolled students on the pretext of trialling a new anaesthetic cream to which he gave the impressive-sounding name of Trivaricane. The students were shown the bottle. On the label were the words
approved for research purposes only
. The experimenter – introduced as a ‘behavioural medicine researcher' – wore a white coat and snapped on a pair of surgical gloves, explaining that she wanted to be sure she wasn't over-exposed to the Trivaricane. After administering the sham cream and giving it a minute or two to ‘work', a mechanical gadget was used to apply a sharp force to the student's fingers, one finger at a time. The students were asked to rate the pain on each finger and reported feeling much less pain on the finger that had been ‘treated'. A British study of headache pills showed that an unbranded, real pill worked better than an unbranded sham pill, but worse than a placebo pill that came in the packaging of a famous brand of headache remedies. The real branded pill worked best of all.

When a person receives a genuine medical treatment and makes a recovery, three things are going on at once. First, the surgical procedure, or the physiologically active pharmaceuticals of the drug, act on the body. Second, the body's superb self-healing system gets to work, its actions enhanced by the patient's expectations of recovery, which are catalysed by the treatment. Third, the patient's belief in the person treating them, or the symbols associated with the treatment, affect their expectations and thus their physiological state. The term placebo effect is used to cover the last two, which of course can take place without the first, but it might be better named the ‘belief effect' – after all, a placebo pill does nothing, by definition. Placebo is just a word for the healing that happens because somebody believes that the treatment they've received will make them better. If you don't believe in a lie, it won't make you better.

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Franklin's scepticism about Mesmerism was evident in a letter he sent, shortly before joining the commission, in reply to a sick man who had asked him whether, in his opinion, it would be worthwhile taking a trip to Paris to see Dr Mesmer. Typically of Franklin, it is written in plain language but is dense with insight:

There being so many disorders which cure themselves and such a disposition in mankind to deceive themselves and one another on these occasions . . . one cannot but fear that the expectation of great advantage from the new method of treating diseases will prove a delusion.

That delusion may, however, in some cases, be of use while it lasts. There are in every great city a number of persons who are never in health, because they are fond of medications, and by always taking them, hurt their constitutions. If these people can be persuaded to forbear their drugs in expectation of being cured by only the physician's finger or an iron rod pointing at them, they may possibly find good effects tho' they mistake the cause.

Franklin hints here at the usefulness of medical lies – they help people feel better without creating dependence on potentially damaging physical treatments. But is it ever acceptable to deceive patients? Many doctors persuade themselves that it is. According to Anne Helm of the Oregon Health Sciences University, between thirty-five and forty-five per cent of all medical prescriptions are placebos. A 2003 study of eight hundred Danish clinicians found that almost half prescribed a placebo at least ten times a year. These aren't ‘pure' placebos; doctors prescribe medications with small active elements in them, though not something that's going to act on the ailment in question.

Although it's commonplace, placebo-prescribing is a controversial practice within the medical community. After all, the healing power of doctors, and indeed, the very possibility of placebo effects, relies in part on the trust that patients place in them. As the philosopher Sisella Bok puts it, ‘to permit a widespread practice of deception . . . is to set the stage for abuses and growing mistrust.' Other parties to the process are forced to become accomplices to the deception; an article in the
Journal of the American Pharmaceutical Association
provides a script for the pharmacist faced with a prescription that is clearly a placebo: ‘Generally, a larger dose is used for most patients, but your doctor believes that you'll benefit from this dose.'

Of course, doctors aren't deceiving for the sake of it; they are usually doing so for the good of their patients, and anyway, identifying what does or doesn't constitute deception in this context is not straightforward. If a doctor prescribes a pill to a patient, knowing that the pill itself will have no effect on their condition but hoping that the act of administering it will encourage the patient's recovery, is he deceiving? He's certainly not being entirely honest. If he were, he would say something like, ‘The pill I'm giving you has no active ingredient that will cure your symptoms, but all you really need is something to believe in, and this will do.' But if he said this, he would quite obviously be undermining the very effect that might lead to the patient feeling better. On the other hand, he doesn't have to engage in outright deception either. Walter Brown, professor of clinical psychiatry at Brown University, suggests that sometimes doctors should be able to tell patients that although the pill they are dispensing contains no active drug, ‘Many people with your condition have found that it helps.'

What definitely
would
constitute deception is if the doctor invented a false ‘scientific' story to explain how the treatment works. This is what upsets scientists about the alternative medicine industry, which seems to borrow, deceitfully, from the language of biomedical science to enhance its own authority. The homeopathic establishment, with its talk of molecule clustering and nanobubbles, dresses up its treatments in the language of pharmacology. What sceptics find infuriating about homeopathy is that it manages to have it both ways, presenting itself as an alternative to traditional medicine while at the same time relying on its vocabulary for a specious authority.

Homeopathic treatments can work, however, even if most evidence suggests they work purely through the belief effect, and from the therapeutic experience of an encounter with a sympathetic practitioner. Given this, even the sceptic might argue it would be wasteful and destructive to ban them from our pharmacy shelves, or indeed from the NHS. Indeed, it might be dangerous for conventional doctors to shun alternative cures entirely. If some patients see conventional medicine and ‘complementary' medicine as a competition between science and caring (or between technology and tradition), then they may refuse conventional treatments that offer their only hope of a cure.

Rather than defending their turf, perhaps evidence-based physicians ought to focus their efforts on expanding it. Already, doctors increasingly accept that the wider, intangible aspects of well-being are important; that a physician who stares at his computer screen while you tell him about your symptoms is less likely to cure his patient than one who looks like he cares; that the best way for a person to stay healthy in old age is to stay socially active – and that these are scientific truths as much as folk wisdoms. But there is a long way to go before our doctors become ‘scientists of the spirit' as well as the body.

Scientifically grounded medicine is a vastly welcome but very late development in the human story. For most of our history we've been blundering from one mistaken idea about how the body works to another. Metaphor, ritual and symbol were all we had for combating disease, whether we knew it or not.
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If people responded positively to the touch of the shaman, the apothecary's elixir, or even harmful treatments like bloodletting – and one of the reasons such treatments persisted is that they often did work – it was at least partly because they believed in them, or in the physician dispensing them.

Lavoisier and Franklin were avid readers of Montaigne, and their report was influenced by an essay of his entitled ‘The Power of the Imagination' (1574), in which he argued that medicine was based on deceit. Physicians, said Montaigne, exploit the credulity of their patients with ‘false promises' and ‘fraudulent concoctions'; if their cures work it is mainly because of the patient's lively imagination. He described a woman who was convinced that she had swallowed a pin in a piece of bread and was ill as a result. Her doctors didn't believe her but had no success in relieving her symptoms, until one day they gave her an emetic and secretly placed a needle in her vomit. She was cured. (The metaphor of exorcism or excision, in which something malign – a spirit, a tumour, a gallstone – is removed from the body by the healer, is one of the most enduring and powerful tropes of medicine. A 2009 study found that patients undergoing surgery to correct painful spinal tears reported greater improvement when, after the operation, they were shown fragments of the removed disc.)

Although nobody quite knows why it is that beliefs – regardless of whether they're true – are so central to our physical well-being, the behavioural scientist Dylan Evans has proposed an intriguing explanation. Noting that we are the only animal to practise medicine (chimps take care of each other when injured, but primatologists have never observed one chimp giving medical assistance to another), he suggests that it began as a way of stimulating positive beliefs about recovery:

By the time the human lineage began to diverge from that of the chimpanzees, some five million years ago, the capacity for immune conditioning was well established. At some point our ancestors discovered they could activate it deliberately. They found quite by chance that they could train their immune systems to respond to certain stimuli in ways that felt quite beneficial. These stimuli – dabbing leaves on each other's wounds, perhaps, or giving each other special herbs when sick – were the origins of medicine.

Early humans who had access to the power of the belief effect – activated through culture – would have secured an advantage over those who did not. In other words, the very survival and reproduction of our species has relied on our ability to deceive ourselves and others into thinking that we are going to get better even when there is no objective reason why we should. Small wonder, then, that lies continue to exert such a far-reaching effect on our health and happiness.

The power of stories to shape our lives

We tell ourselves stories in order to live.

Joan Didion

In 2002, the research director of the pharmaceuticals giant Merck announced that his company's aim was ‘to dominate the central nervous system'. According to Steve Silberman of
Wired
magazine, the key to this grandiose ambition was the development of a powerful new anti-depressant, codenamed MK-869, which would enable Merck to take on competitors like Pfizer and GlaxoSmithKline who had created some of the best-selling and most famous anti-depressants. In early tests, MK-869 had performed brilliantly: those taking it reported pronounced and lasting improvements in their sense of well-being. But when it was tested against a placebo pill MK-869 suddenly looked less impressive. The volunteers in the group taking the placebo felt much happier too, and to a degree comparable to those who had taken the real thing. In trial after trial, Merck couldn't prove that MK-869 worked better than a sugar pill. In the evocative phrase used by the industry to describe a drug that fails in testing, MK-869 crossed ‘the futility boundary', and was abandoned.

It was far from the only one to do so. In the first decade of the twenty-first century, the failure rate of new drugs in trials against placebos was higher than it had been since such testing became standard. Expensively produced, highly effective anti-depressants consistently failed to prove themselves against placebos – as did new wonder treatments for schizophrenia, Crohn's disease, and Parkinson's disease. It wasn't just new drugs that were crossing the futility boundary. Drugs that had been around for decades, including some of the industry's greatest hits, like Prozac, have faltered in recent tests against placebos. If they were to undergo testing by the regulatory authorities now, they might not pass. These medications aren't any weaker than they used to be, and nor are new drugs becoming pharmacologically less sophisticated – quite the opposite. But in the competition to dominate our central nervous systems, the expensively developed drugs produced by the pharmaceutical companies are facing a seemingly much improved, terrifyingly effective competitor: the sugar pill. If they want to keep charging high prices for their drugs, they will need to find out why this is.

The answer probably doesn't lie in the laboratory. We can get closer to it by way of wine-drinking, the ailments of war veterans and the marketing of breakfast cereals.

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For over seventy years the cereal brand Shreddies has been a fixture of the supermarket shelves and kitchen cupboards of Britain, Canada and New Zealand. Anyone who has grown up in those countries will instantly recognise these squares of waffled whole wheat. Shreddies is owned by Post Cereals, which is part of the global food company Kraft. For marketers, a brand like Shreddies is both a blessing and a problem. On the one hand, it is so well-known and so entrenched in the repertoires of shoppers that its sales can be relied upon to provide a steady stream of revenue. On the other, familiarity breeds passivity; consumers barely notice brands they know well and are easily distracted by more novel and exciting alternatives. The challenge for a brand manager, therefore, is to do what the Russian school of formalist criticism described as the task of literature: to defamiliarise the familiar. Or in this case, to make Shreddies seem new again.

This is hard – there are only so many things you can say about a square of wheat, and over the preceding decades pretty much all of them had been said. But this was the problem presented to the Toronto office of ad agency Ogilvy and Mather in 2006, when the Shreddies client asked the agency to come up with a new poster and TV campaign to give its venerable brand a jolt of excitement. It would be the first time for several years that serious money had been spent on advertising Shreddies, and the brief went to all of the agency's senior creative teams, who were asked to work on ideas for a TV and poster campaign, and to make it their first priority. At the same time, another, somewhat less high-profile brief landed on the desk of a twenty-six-year-old copywriting intern called Hunter Somerville. He was asked to come up with a concept for the back of the Shreddies box – something new and fun to catch the eye of shoppers. He faced the same problem as his more senior colleagues, albeit in a miniature form: to say something about Shreddies that was neither a cliche nor a lie.

After a career as an improvisational comedian, Somerville had come to advertising on the basis that it couldn't be that difficult to pen an advertising script that was funnier than most of those he saw on TV. As a consumer, one of the things that annoyed Somerville about ads was the way they constantly made up phony reasons to say ‘new' when it was patently clear they had nothing new to say at all. ‘Now with added
X
' or ‘Now with all
X
removed'; it all seemed fraudulent, and a little desperate. Now that he was on the other side, Somerville at least understood where the desperation came from. When deadline day arrived he only had one idea, and it was so absurd, so deeply silly, that he feared he might be marched out of the building the moment he shared it. ‘I just thought it was funny,' he told me. Somerville's idea was to show a picture of a Shreddie rotated by forty-five degrees so that it balanced on its tip. This, the copy announced, was a ‘new' type of Shreddie – the ‘Diamond Shreddie'.

Later that day, the creative directors of the agency reviewed ideas for the new campaign and didn't see anything that excited them. When Somerville presented his idea to them, there was a moment's silence. Then his bosses began shaking with laughter. Diamond Shreddies was the funniest thing they'd seen all day. ‘It was almost embarrassing, how much they laughed,' Somerville said later. He was asked to write TV scripts along the same lines, followed by posters, and a website. The more the creative directors saw how the idea might play out, the more they liked it. When they took it to Post's director of marketing, she loved it too.

Somerville's silly idea became the basis of a major advertising campaign, the premise of which was that Shreddies were launching an exciting new format – an ‘angular upgrade', devised by a team of ‘cereal scientists', that would revolutionise breakfast-time. Packs of Diamond Shreddies – with an outsized and upended Shreddie on the front – appeared on supermarket shelves and billboard poster sites. Mimicking the conventions of product launches, the agency conducted focus groups on the new format and filmed them. Two plates were presented to the group, each with several rows of Shreddies laid out on them. On one plate, the Shreddies were turned at an angle. The focus group moderator asked participants to sample one Square Shreddie and one Diamond Shreddie each. Consumers generally preferred the Diamond Shreddie: ‘It had more flavour,' said one man; ‘It was crunchier,' said another.

The campaign was tongue-in-cheek, though plenty of consumers took it seriously, writing emails to Post expressing either approval or disgust at the brand's new manifestation. Others took the joke and ran with it; one man auctioned what he claimed to be ‘the last square Shreddie' on eBay and sold it for thirty-six dollars.
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More than ten thousand people voted online for their favourite shape. In business terms the campaign proved a stunning success: after years of steady but unspectacular growth, sales of Shreddies soared. Hunter Somerville was delighted that so many people responded so positively, though he wasn't particularly surprised. ‘Sometimes I believe the diamonds taste better myself,' he laughed.

Rory Sutherland, a British ad executive and spokesperson for the industry, argues that the story of Diamond Shreddies is merely an extreme illustration of the way all modern branding works: as a form of placebo. Whether it's sneakers or soft drinks, products in most categories haven't changed fundamentally in years and aren't likely to any time soon – and often there's little to choose between competing offers. The job of advertising, says Sutherland, isn't just to communicate information but to create ‘symbolic value', for which consumers are willing to pay. If you believe that wearing this brand of trainers will make you a better basketball player, then you'll pay a higher price for them.

You may just play better basketball as a result. Economists at the Massachusetts Institute of Technology approached students entering the university's gym and offered to sell them a bottle of SoBe Adrenalin Rush, an ‘energy drink' that promised to impart ‘superior functionality.' Some of the students were sold the drink at full price; others bought it at a discount. After they had exercised the students were asked if they felt better or worse than they usually did after working out. Those who drank the SoBe said they felt a little less fatigued than normal. That was plausible enough – the drink contained a shot of caffeine – but more interesting was that those who paid full price for the drink reported less fatigue than those given the discount. Striking as it was, this result was based on self-assessment, so the researchers designed a more objective test, this time of SoBe's claim to provide ‘energy for the mind'. Once again, half the participants were sold the drink at full price, and the others got a discount. They were then set a series of word puzzles. The people who paid the discounted price solved about thirty per cent fewer puzzles than those who paid full price. They were convinced that their drink was less potent, and this belief made them a little stupider.

Advertisers are often accused of selling lies to the public, but advertising can be deceptive without being dishonest. It's true that, for example, no deodorant really has the power to turn adolescent boys into girl magnets. But the truth status of most advertising is like that of fiction; consumers are openly invited to suspend disbelief. Both the advertiser and the advertised-to generally understand that a little deception (or self-deception) is good for us. The person who prefers the taste of Heinz Baked Beans to other brands but fails a blind taste test isn't necessarily being duped; the brand is a perfectly legitimate component of her pleasure in the food, and if the pleasure of using an Apple MacBook or driving a BMW is bound up with the associations we have with those brands, it seems reasonable for the brand-owners to charge more for the enhanced experience.

To think otherwise is to adopt a rather narrow view of the satisfactions people gain from shopping. It's often assumed that people buy things solely to gain material satisfaction. But they are also paying, knowingly and willingly, to be deceived, in a mentally and emotionally stimulating way. In
The Romantic Ethic and the Spirit of Modern Consumerism
, the sociologist Colin Campbell proposes that consumption is not so much about mere acquisition as it is about the languorous pleasures of imagining. For Campbell, the modern consumer is a self-deceiving ‘dream artist', with ‘the ability to create an illusion which is known to be false but felt to be true'; an illusion that is woven around the object of desire.

In her short story
The New Dress
, Virginia Woolf describes a young woman trying on a dress for the first time:

Suffused with light, she sprang into existence. Rid of cares and wrinkles, what she had dreamed of herself was there – a beautiful woman. Just for a second . . . there looked at her, framed in the scrolloping mahogany, a grey-white, mysteriously charming girl, the core of herself, the soul of herself; and it was not vanity only, not only self-love that made her think it good, tender, and true.

The dress allows Woolf's protagonist to dream up – to try on – a new version of herself. When she first wears the dress to a party, however, the dream vanishes. Tortured by the conviction that everyone thinks she looks ridiculous, she is ‘woken wide awake to reality'. Campbell argues that the woman in Woolf's story enacts the modern consumer's oscillation between willed self-deception and disillusion. The reality of a product is never quite as good as the dream – but then if it was, there would be no reason to dream again. The product itself is merely an excuse to experience the pleasures of anticipation, longing and pretending. We pay for the reflection, not just the dress; a reflection that advertising helps to create.

Apart from anything else, says Rory Sutherland, enriching the symbolic value of the brand via advertising is a more environmentally responsible way of improving a product than using more or better materials. Meaning is not a finite resource.

Thinking about such mutually satisfactory deceptions can make us uncomfortable because we tend to imagine there's a realm of pure, spontaneous, authentic experience, over which those wily advertisers draw a veil of deceit (it's that serpent in the garden again). But our physical and aesthetic sensations are inextricable from the meanings we attach to things. The practice of wine-buying tells us something about the relationship between our experience and our beliefs. The fortunes of individual wines, and indeed entire wineries, turn on the decisions of experts who award ratings and dish out medals in competitions, a system built on the premise that a given wine has something like an objectively measurable and consistent quality. The work of Robert Hodgson, published in the
Journal of Wine Economics
, places a large question mark over this assumption.

Hodgson is a retired professor of statistics who runs a small winery in Humboldt County, California, and got interested in the question of why a wine of his might win a gold in one competition and come nowhere in another. So he did something nobody had done before: he performed a large-scale quantitative analysis of the judgements of wine experts, running his own blind taste tests with judges from the California State Fair Wine Competition, and analysing the data from hundreds of wine competitions. He found that judges often gave the same wine very different scores, and that gold medals seemed to be spread around at random, rather than following the same wines consistently.