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Science and Engineering Ethics (2004) 10, 37-42

The Placebo Effect in Popular Culture*


Mary Faith Marshall
Kansas University Medical Center, USA

Keywords: placebo, placebo effect, randomized clinical trial, popular culture, literature, film

ABSTRACT: This paper gives an overview of the placebo effect in popular culture,
especially as it pertains to the work of authors Patrick OBrian and Sinclair Lewis. The
beloved physician as placebo, and the clinician scientist as villain are themes that
respectively inform the novels, The Hundred Days and Arrowsmith. Excerpts from the
novels, and from film show how the placebo effect, and the randomized clinical trial,
have emerged into popular culture, and evolved over time.

One of the best jokes in my collection of medical humor is a cartoon depicting


emergency medical technicians rushing a patient in extremis into the emergency room;
the head technician, calling out to the attending physician on duty exclaims: Placebo
overdose he only thinks hes dead!
The joke attests to the power of suggestion as the underlying mechanism of the
placebo effect, and also lays claim to the pervasive presence of placebo in popular
culture. For the average person, the term placebo conjures an image of a sugar pill, or
other inert substance, or, for those slightly more sophisticated, a sham procedure.
Books and movies, however, have found ways of dramatizing placebo far beyond the
simple inert substance provided during a randomized clinical trial, or the sugar pill
prescribed for the hypochondriac.
The tools of shamans and witchdoctors, for example, have been widely reported in
the scholarly literature and portrayed in novels and film as having both positive and
negative health effects through the suggestive means of charms or spells. In popular
culture, at least, negative effects such as insanity, coma or death are much more
frequently portrayed as manifestations of witchdoctoring than are positive effects. The
mere presence of a shaman or witchdoctor, or the news that an individual is the object
* An earlier version of this paper was presented at an international conference, Placebo: Its Action
and Place in Health Research Today, held in Warsaw, Poland on 12-13 April, 2003.
Address for correspondence: Mary Faith Marshall, Kansas University Medical Center, 2010
Robinson, Box 1025, 3901 Rainbow Boulevard, Kansas City, Kansas 66160, USA; email:
mmarshall@ kumc.edu.
Paper received, 18 November 2003: accepted, 8 December 2003.
1353-3452 2003 Opragen Publications, POB 54, Guildford GU1 2YF, UK. http://www.opragen.co.uk

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M. F. Marshall

of a charm or spell is enough to invoke the desired psychobiological reaction. Fear, like
laughter, is a powerful psychological and biological weapon. Note, for example, that
among the ideal characteristics of an effective bioweapon, aside from the agents
infectious properties or other physical effects, is its ability to instill panic in a mass
population. The positive, or healing effect of a native healer or physicians physical
presence, or even of his or her garb, arises less frequently in either popular literature or
film.
Two very different portrayals of the physician, both appearing first in literature,
and subsequently adapted to film, are found in the works of Patrick OBrian and
Sinclair Lewis. In OBrians book, The Hundred Days, his physician protagonist,
Stephen Maturin, is much beloved by his fellow sailors. Lewis main character on the
other hand, Martin Arrowsmith, (in the book, Arrowsmith) is vilified for his scientific,
and seemingly inhumane approach to finding a cure for the plague. Excerpts from each
of the texts will follow to illustrate how conceptions of the physician, and of placebo,
have evolved and diverged over time.
Master and Commander: The Far Side of the World has been one of the most
publicized and long awaited film events of 2003. The film, starring Russell Crowe and
directed by Peter Weir, opened November 14, 2003 to excellent international reviews
and a strong box office. In addition to the draw of its Oscar award-winning star, Mr.
Crow, and its acclaimed director, Mr. Weir, the film owes a large part of its success to
the international cult-like following of the historical naval fiction upon which it is
based. The twenty books that comprise British author Patrick OBrians series, set
during the Napoleonic era, have been reviewed by Richard Snow of the New York
Times as the best historical novels ever written.3
The main characters in the series are British naval Captain John Aubrey, and his
best friend and colleague, Stephen Maturin, a physician, naturalist, and British
intelligence operative. Maturin, a real physician (as opposed to a mere ships surgeon,
whose professional status equals that of a barber) is esteemed by his shipmates for his
professional knowledge and clinical skills. Conversely, he is OBrians foil for
instructing the reader in all things nautical, for try as he might, Maturin, (a scholar and
member of the British Royal Society), can scarcely manage to assimilate any naval
knowledge. Nautical terms and naval routines seem to disappear through a mental sieve
in his brainpan. Maturin is a true lubber, or landsman, even after twenty years aboard
ship. This failing, in the minds of his shipmates, is compounded by Maturins physical
aspect, for he is, in his dress, a rather shabby, unkempt person, much to the dismay of
his naval colleagues, for whom cleanliness and order are not only cardinal virtues, but
a way of life. In spite of his failings, however, Maturin is cherished by his shipmates.
OBrian takes great pains to characterize sailors of the Napoleonic era as
supremely superstitious fellows. A jonah, for example, is a hapless crew member or
officer (often unpopular to begin with) who is believed to bring bad luck on a ship by
his mere presence, (as also, with some exceptions, do the presence of clergy or women
aboard ship). Dr. Maturin, however, has an opposite, salutary effect on his fellow
mariners. As will be seen in the following excerpt from The Hundred Days, Maturins
physical presence alone, and the sailors awe of his clinical gifts have a powerful
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The Placebo Effect in Popular Culture

placebo effect on his shipmates. The excerpt illustrates the complex relationships on
board Aubreys ship, the Surprise, as well as OBrians superb writing style his depth
of character, and his scholarly knowledge of the British Royal Navy:
A little before the evening gun Preserved Killick, Captain Aubreys steward,
an ill-faced, ill-tempered, meager, atrabilious, shrewish man who kept his
officers uniform, equipment and silver in a state of exact, old-maidish order
come wind or high water, and who did the same for Aubreys close friend and
companion, Dr. Stephen Maturin, or even more so, since in the Doctors case
Killick added a fretful, nurse-maid quality to his service, as though Maturin
were not quite exactly a fully intelligent being, approached Stephens cabin.
It is true that in the community of mariners the not quite exactly opinion was
widely held; for although Stephen could now tell the difference between
starboard and larboard, it still called for some reflection: and it marked the
limit of his powers. This general view, however, in no way affected their deep
respect for him as a medical man: his work with a trephine or a saw, sometimes
carried out on open deck for the sake of the light, excited universal admiration,
and it was said that if he chose, and if the tide were still making, he could save
you although you were already three parts dead and mouldy. Furthermore, a
small half of one of his boluses would blow the backside off a bullock. The
placebo effect of this reputation had indeed preserved many a shattered sailor,
and he was much caressed aboard.1
The physician/scientist Martin Arrowsmith, protagonist of Sinclair Lewis Nobel
Prize-winning novel, Arrowsmith, enjoyed a very different reputation among most of
his peers and acquaintences. Dr. Arrowsmith, a young physician torn between the fame
and fortune that attend American pseudoscience in the 1920s and 1930s, and the
derision and scorn directed at those who search after the truth using pure science,
travels from America to a plague infested Caribbean island to test his serum, a possible
cure for the plague. Arrowsmith is, like Sinclairs earlier books, (Main Street, a satire
of small town life in America, and Babbit, a satire of life in the big city), also a satire,
an indictment really, not of social setting, but of widespread commercialism in
medicine and science.
One of the most powerful moments in the book, and even more so in the films
portrayal of the scene, occurs when Dr. Arrowsmith tries to convince the colonial
government of St. Hubert, a Caribbean island endemic with the plague, to let him
conduct a controlled clinical trial of his anti-plague serum, his phage. Although the
proposed trial does not contain a placebo arm, it does involve a randomized treatment
methodology. Dr. Arrowsmith proposes to a Special Board of the colonial
government of St. Hubert, (an island under a state of quarantine), that half of the
islands citizens receive the serum, while the other half of the islanders receive
treatment as usual. The response from the (needless to say, white male) Special Board
members is moral outrage bordering on apoplexy at the idea of withholding a
potentially effective treatment from anyone.
Witness the following excerpts from the book:
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M. F. Marshall

Martin banged on the table and quoted his idol: Up to the present, even in the
work of Erlich, most research has been largely a matter of trial and error, the
empirical method, which is quite the opposite of the scientific method, by
which one seeks to establish a general law governing a group of phenomena so
that he may predict what will happen.
Martin was guided down the stinking street of cottages palm-thatched and
walled with cow-dung plaster on bamboo laths, cottages shared by the roosters
and the goats. He heard men shrieking in delirium; a dozen times he saw that
face of terrorsunken bloody eyes, drawn face, open mouthwhich marks
the Black Death; and once he beheld an exquisite girl child in coma on the
edge of death, her tongue black and round her the scent of the tomb. They fled
away to [the village] Point Carib and the trade wind, and when Inchape Jones
demanded, After that sort of thing, can you really talk of experimenting? then
Martin shook his head, while he tried to recall the vision of Gottlieb and all
their little plans: half to get the phage, half to be sternly deprived. It came to
him that Gottlieb, in his secluded innocence, had not realized what it meant to
gain leave to experiment amid the hysteria of an epidemic. He went to the Ice
House; he had a drink with a frightened clerk from Derbyshire; he regained the
picture of Gottliebs sunken, demanding eyes; and he swore that he would not
yield to a compassion which in the end would make all compassion futile.
The Special Board met in Parliament House, all of them trying to look not like
their simple and domestic selves but like judges. With them appeared such
doctors of the island as could find the time. While Leora listened from the back
of the room, Martin addressed them, not unaware of the spectacle of little Mart
Arrowsmith of Elk Mills taken seriously by the rulers of a tropic isle headed by
a Sir Somebody. Beside him stood Max Gottlieb, and in Gottliebs power he
reverently sought to explain that mankind has ever given up eventual greatness
because some crisis, some war or election or loyalty to a Messiah which at the
moment seemed weighty, has choked the patient search for truth. He sought to
explain that he couldperhapssave half of a given district, but that to test
for all time the value of phage, the other half must be left without itthough,
he craftily told them, in any case the luckless half would receive as much care
as at present. ..The Special Boardvoted only to give the matter their
consideration while still men died by the score each day, and in Manchuria as
in St. Hubert they prayed for rest from the ancient clawing pain.3
The dialogue of this particular scene as portrayed in screenwriter Sidney Howards
film version of Arrowsmith, with Ronald Coleman and Helen Hays in the leading roles,
(and directed by John Ford) is much more emotional and vehement. The main
protagonists, in this scene, are Dr. Arrowsmith and Sir Robert Fairlamb, the head of the
colonial government. The members of the board serve as a Greek Chorus.
Arrowsmith: I shall divide my group into two halves. To one I shall give
injection of our serum. I shall deprive the other half of any injections
whatsoever. I shall then watch which half resists the plague more successfully.
When I have done that I shall know what our serum is worth.
Board Members: Good God! The man is a lunatic!
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The Placebo Effect in Popular Culture

Sir Robert: Order, order! I can handle this! You mean to say you cant find any
other way to test your serum?
Arrowsmith: There is no other way.
Sir Robert: You call yourself a doctor, and want to see half your patients die?
Arrowsmith: Oh no sir! The uninjected half will be fully as well taken care of
as they are at present!
Sir Robert: You actually propose using inhabitants of this island as you use
guinea pigs in your laboratories?
Arrowsmith: Well, You put it unpleasantly, Sir Robert, but that is exactly what
I do precisely propose. And for precisely the same benefit to mankind.
Sir Robert: Well, we decline the honor! In the name of civilization!
Arrowsmith: I think civilizations on my side Sir Robert. You see only this one
epidemic on this island. I have to see whole continents and generations of
children yet unborn. In China, in India, and even, it seems, in your own West
Indies. I have to say to all humanity this is the prevention! This is the cure!
You can count on it as you count on quinine for malaria and castor oil for the
belly ache. Because that is what humanity wants to hear!
Sir Robert: Well humanitys not going to hear of it at our expense! While
youre in this island, youll stick to your doctoring.
Arrowsmith: That, sir, is for me to say, not you.
Sir Robert: What the devil do you mean?
Arrowsmith: I mean that if you prevent this experiment, my instructions leave
me free to withhold my serum until you come to heel.
Sir Robert: Confound your instructions!
Board Members: What are we going to do, Sir Robert? Sir Robert, perhaps we
should reconsider!
Sir Robert: Order! This meeting is adjourned.
Board Members: But Sir Robert, what shall we do?
Sir Robert: Die like men! Before we let these bandits turn us into a shambles!
If it werent for the quarantine, Id drive them off the island with whips and
scorpions!4
The evolution of the concept of placebo and the ethical issues attendant on their
use in controlled clinical trials were explored recently at an international conference
sponsored by the National Institutes of Health, entitled The Science of the Placebo:
Toward an Interdisciplinary Research Agenda. Conference participants defined
placebo as the beneficial physiological or psychological changes associated with the
use of inert medications, sham procedures, or in response to therapeutic encounters and
symbols, such as the white coat.5 Meeting co-director, Dr. Arthur Kleinman and his
colleagues observed that this new legitimacy is altering and expanding the concept of
the placebo from its pejorative 19th century definition as a medicine adapted more to
please than benefit the patient, to one that encompasses many features occurring in the
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M. F. Marshall

course of patient-provider interactions that can positively affect health and well-being.
This difference in attitude is in itself the product of progress in science.5
That said, there is evidence that some venues of popular culture still cling to
vestiges of the pleasure principle. Witness, for example, the progressive rock group,
Placebo, whose compact disc titles include Without You Im Nothing, Black
Market Music, and Sleeping with Ghosts. The band (a truly international
collaboration the singer/guitarist is American, the bassist Swedish, and the drummer
English) describes itself as punk pop for postponed suicides.6 Here are the lyrics to
the title song, Black Market Music:
I was never faithful, and I was never one to trust; Borderline and skitzo and
guaranteed to cause a fuss
I was never loyal except for my own pleasure zone; Im forever black-eyed, a
product of a broken home.7
If thats a little too far out for the average reader, consider the new publication
(perhaps magazine is apt) for physicians called Placebo Journal.8 It ascribes to the
thesis that laughter is, indeed, the best medicine, especially for stressed and
overworked physicians. The journals editor, Michael Farrago, MD, a family physician
practicing in Auburn, Maine, USA describes the journal as a means to empower
physicians with a skill that is sorely lacking humor. By using real life medical
stories that are sent in by physicians themselves, doctors can now laugh at themselves
and their patients and bring a little joy back to their lives. Like a placebo pill, our
journal produces a positive affect from something of very little substance.8
The stories include, for example, a physicians embarrassment and dismay when
he discovers, gazing in the mirror while washing his hands, that he has just conducted
an entire session with a patient, (including a physical examination), with a rather
obvious booger hanging from his nose. Not Patrick OBrian, certainly, or Sinclair
Lewis. But medical humanism for sure and whos to say laughter isnt the best
medicine, after all?
Acknowledgement: The author wishes to acknowledge the following for their assistance with this
manuscript: Paul Lombardo, McAlister Marshall, William Parks, Sally Webb, Jeanine Gage, and
Christopher Crenner.

REFERENCES
1. Snow R. (1991) An Author Id Walk the Plank For, The New York Times Book Review
(January 6, 1991).
2. OBrian, P. (1998) The Hundred Days. W.W. Norton & Company, New York.
3. Lewis, S. (1925) Arrowsmith. Harcourt, Brace & World, Inc., New York.
4. Arrowsmith 1932, Samuel Goldwyn
5. Kleinman A, Guess HA, Wilentz JS (2002) in: Engel, L.W., Guess, H.A., Kleinman, A., &
Kusek, J.W. eds. The Science of the Placebo: Toward an Interdisciplinary Research Agenda.
British Medical Journal Press, London: (1).
6. http://launch.yahoo.com/artist/artistfocus.asp?artistID=1021104
7. http://www.lyricsfreak.com/p/placebo/109340.html
8. http://www.placebojournal.com

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