Placebo Effect in Halacha

The last post got me thinking about the how the Placebo Effect works with halacha. In the last post we discussed what type of medicinal treatments are permitted according to halacha, and which are prohibited due to darchei haemori. We concluded that post as follows:

The Rashba seems to be saying that in order for a medicine to be considered rational we don't have to know why it works. We only need to have a rational basis for using the medicine. A rational basis can exist due to logic (it makes logical sense that this medicine should work even though it hasn't yet been tested) or due to observation (we have no idea why it works we just have observed that it does). What is forbidden is to use a medicine that we have no rational reason to believe works. If it makes no sense why it should work, nor has it been observed to work then it is forbidden.

It's the observation line that I want to focus on. As I wrote in the post, there are two reasons why a particular medicine or medical treatment could be considered rational. One is that it is logical that the treatment should work. Even if it is a totally new treatment that hasn't been tested it can still be considered a rational treatment if their is some logical reason why doctors think it will work.

The second reason that a treatment could be considered rational is because we have observed that it works - even though we don't know why or how it works. What's interesting to consider is that ever since the early 20th century medical science has been working under the premise that there exists a placebo effect. Meaning that a completely ineffective therapy can still work, simply because the patient believes that it will work. The question therefore is - what do we do with the rishonim who permitted certain medical treatments because those treatments were observed to be effective. Was that observation a "real" observation or was it just the placebo effect working? And in general, must we take the placebo effect into account as far as halacha? Do we define observation l'halacha the same way scientists define it? If we do, then that would mean that one could never take any medicine or medical treatment that hadn't been tested in a placebo-controlled study in a double-blind fashion (unless there was a logical reason why the medicine should work).

The placebo effect does make it into halacha in another scenario. Imagine a patient who believes that some non-kosher medicine will heal him. Now, the doctors actually don't believe it. It's totally untested and illogical. The question becomes is it considered a valid medical treatement or not? If it is, then we might be able to use it even though it isn't kosher (assuming other necessary conditions are met). If not, we surely cannot give someone non-kosher for no reason.

How can it possibly be considered a real medical need? The answer is that since the patient believes it will work it might just help him. Basically, it's the placebo effect at work. In fact there are poskim who have permitted just this case in certain specific situations for exactly this reason. The psychological benefit of taking the medicine is enough to declare it "medical" and permit it. Because the patient truly believes that this might work it becomes a possibly effective treatment and may become muttar even if it isn't kosher.

This then brings us back to our question regarding the times of the rishonim. Even if there were no placebo-controlled studies, the fact is that the people fully believed that these treatments worked. They had even "observed" them working. Therefore, the treatments, in a sense, did work precisely because people believed it! Accordingly, this may be enough halachically to be considered a real medicine and it becomes muttar. Just some food for thought.

* No post on Talking in Learning is intended halacha l'maaseh. Always consult your halachic authority for final rulings.

Segulos and Darchei HaEmori

The Tosefta in Shabbos (Chapters 7 & 8) lists various practices which are prohibited due to the fact that they are darchei haemori. For example, putting thorns in a window to protect a pregnant woman or tying an iron to one's bed. These things all have one basic common feature. They are irrational - meaning they are not scientifically or observably proven remedies. (We will come back to this to try to better define what is considered "irrational".)However, the gemara in Shabbos 67a has a seemingly different rule regarding medicine. Abaye and Rava say that "anything done for healing isn't darchei haemori". The mishna applies this rule to several seemingly irrational medical treatments - tooth of a fox, egg of a grasshopper etc.

How do we reconcile these two sources? Here we will present three rishonim who write on the issue:

Rambam - The Rambam in Moreh Nevuchim 3:37 (see also Rashi in Shabbos there) seems to say that, in fact, when it comes to medicine the rule is the same as any other segulah. If a method of healing is not observable by medical science it is forbidden. He seems to learn that the methods mentioned in the mishna in Shabbos were considered rational healing methods.

Ran - The Ran (Drashos HaRan 12) disputes this approach. He learns that when it comes to healing there are two appropriate methods. There are some healing methods that are physical and there are others that are non-physical. Both are appropriate as long as they effective methods that are shown to work. The only healings that are forbidden are ineffective ones which was the way of the Emori - who used silly useless things to heal.

Rashba - The Rashba (Shu"t 413) writes that the Rambam would agree with this position of the Ran. He compares the non-physical healings of the Ran to a magnet. A magnet has power that cannot be seen - yet of course it works. It is a rational thing to believe that a magnet will draw things to it. So too with non-physical healings. As long as they are established as working, they are perfectly rational and the Rambam would certainly agree that they are permitted.

What seems to be at issue here is really how we define rational. The Rashba seems to be saying that in order for a medicine to be considered rational we don't have to know why it works. We only need to have a rational basis for using the medicine. A rational basis can exist due to logic (it makes logical sense that this medicine should work even though it hasn't yet been tested) or due to observation (we have no idea why it works we just have observed that it does). What is forbidden is to use a medicine that we have no rational reason to believe works. If it makes no sense why it should work, nor has it been observed to work then it is forbidden.

At the end of this discussion it would appear that all three of these rishonim agree that in the mishna in Shabbos there was some rational basis for using those particular methods. Had there been no rational basis it would have been forbidden.

*For a much more in-depth discussion on this issue see RJJ Journal Vol. 54 - Segulot, Superstitions, and Darchei Emori by Rabbi Yitzchok Gutterman.