Double Blind

by Edward St. Aubyn

  In any case, she must try to do better next time she spoke to Olivia. For the moment, though, she wanted to rest and stare at the sea, albeit a little guiltily, and daydream for a while. First, she had to force down the remains of the Chinese herbs she was taking twice a day. She had prepared the bitter brew instead of breakfast, but Olivia’s call had interrupted her halfway through consuming it. In the World of Four Objects into which her diagnosis had marched her, like a bored prison guard pointing out the amenities of a cell – statistic, poison, scalpel, radiation – there was no room for Chinese herbs, or a low-sugar and low-carb diet that starved the tumour without starving the patient, or medicinal mushrooms, or enhanced mental health. There was ‘no evidence’ that any complementary approach worked because the presumption that it did not work prevented funding for the expensive, controlled, large sample, double-blind, replicable experiments that would constitute ‘evidence’. Nobody could be more grateful than Lucy that chemotherapy and surgery and radiation were available if her tumour became active enough to warrant their deployment, but she remained sceptical that there were no other actions to take, no other factors in play. How could her general fitness, the strength of her immune system, her will to live and her levels of stress make no difference? She wanted to create an environment that was as inimical to her cancer as possible and as favourable to the strength she would need in order to live with it. She hoped to add many years to the ‘long right-hand tail’ of the prognostic graph and felt that it was unscientific to assume that only blind luck and three types of aggression could carry her there.

  While proper scientists defended true methodology by pouring boiling oil and dropping rocks on the besieging hordes of pseudoscientists, with their diets and their herbs, their acupuncture needles and their Ayurvedic spices, their meditation practices and yoga positions, it turned out that some parts of the citadel they were defending were rotten by their own ‘double blind’ standards. A ‘replication crisis’ was rippling through one discipline after another. Carl Sagan’s remark that extraordinary claims required extraordinary proofs, so often quoted by Bill Moorhead, didn’t mean that orthodox claims needed no proof at all, and yet many of those claims, which had taken on the complacency of unexamined assumptions, had recently been held up to the ordinary test of being replicable, and failed. The crisis itself had now been given the imprimatur of serious science by appearing in Nature and all other leading scientific journals. There was no need to storm the melting citadel; in fact, it aroused Lucy’s pity. She didn’t want to replace dogmatism with an equally obstinate iconoclasm, she just wanted those parts of the impressive stone walls that had been borrowed from the prop department to be sent back to the warehouse where they belonged with the other fake boulders and soft battlements; with the debris of broken theories, of phrenological busts and treatises on phlogiston, and giant pre-Copernican maps of the cosmos painted with lapis lazuli and gold.

  ‘Hi, baby,’ said Hunter, stepping on to the terrace, carrying two glasses. ‘Emile just made this juice for us. It’s got kale and beetroot and flax oil – I can’t remember all the ingredients, but it’s a super-food cluster-fuck that means we’re going to have to face up to our immortality.’

  ‘“The woods decay, the woods decay and fall … Me only cruel immortality consumes,”’ Lucy quoted wearily.

  ‘Hang on, I’m having one too. This is an immortality pact.’

  ‘Farewell, cruel death!’ said Lucy, taking the drink with a smile.

  ‘So, what’s happened in the agonising hour of separation since I last saw you?’ asked Hunter.

  ‘Well, Olivia told me she was pregnant.’

  ‘No kidding,’ said Hunter.

  ‘Funny you should use that phrase,’ said Lucy in an astute German accent.

  ‘Okay, so they’re kidding,’ said Hunter, ‘but are they serious? It’s unplanned – I assume.’

  ‘Yes, but not necessarily unwelcome,’ said Lucy, taking a sip of her death-threatening juice. ‘They’re talking it through in the next few days.’

  Hunter leant over and gave Lucy a kiss on her beetroot-stained lips.

  ‘Apart from that, are you feeling well?’ he asked.

  ‘I feel great,’ said Lucy. ‘After talking to Olivia, I just lay here daydreaming and thinking about complementary medicine and why it works.’

  ‘Or whether it’s a placebo,’ said Hunter.

  ‘Placebos work,’ said Lucy. ‘That’s one of the things that interest me: why is a known therapeutic benefit treated as a glitch?’

  ‘Because it’s based on deception,’ said Hunter.

  ‘What deception?’ asked Saul, who had appeared at the terrace gate, photons raining on the sea behind him and the Calder turning very slowly into a new configuration. ‘Is it okay if I come in?’ he asked. ‘I don’t want to interrupt but there are a couple of developments on the Capo Santo deal that I’d like to run past you before I fly out. We can talk them through on the phone tomorrow, if you prefer.’

  ‘Come on in,’ said Hunter.

  ‘Hi, Saul,’ said Lucy. ‘The “deception” was the placebo effect, and I was asking, where’s the deception? If a patient thinks she’s going to get better and then does get better, why not call it persuasion, or self-healing? The deception is built into the experimental method, it’s not inherent to the effect.’

  ‘Right,’ said Saul, ‘the deception is in making sugar pills look identical to the pharmaceutical pills they are being tested against; the psychogenic effect is real.’

  ‘It’s hard to see how to harness it, though,’ said Hunter. ‘It’s been treated for so long as a sign of human frailty that it should be relegated to the Daniel Kahneman penal colony for cognitive bias, rotten intuition, groundless prejudice and misleading heuristics. I guess the real test is what happens to the effect if people know they are being given a sugar pill.’

  ‘That’s the beauty of it,’ said Saul, ‘it still works. Ted Kaptchuk is the top placebo guy. He’s at Harvard Med and he’s shown that what he calls “open label placebo” has a powerful effect. People know they are taking a sugar pill and sixty per cent of them still report significant relief of symptoms.’

  ‘How would you market that?’ said Hunter.

  ‘Call it Open Placebo,’ said Saul, ‘and get an endorsement from Harvard Med. The margins would be incredible: close to zero cost for manufacturing the product and at the same time a moral responsibility to augment the patient’s sense of receiving something valuable by pricing it up.’

  ‘Could they not be sugar pills?’ said Lucy. ‘It clashes with my diet, and with everyone’s dental health.’

  ‘No problem,’ said Saul, ‘but it mustn’t be something that anyone else is claiming is beneficial, otherwise it’ll get lost in the supplement zone.’

  ‘I’m enjoying the supplement zone,’ said Lucy. ‘Just because something is actually beneficial, like this fabulous juice, doesn’t mean that my conviction that it’s beneficial can’t give it a placebo turbo.’

  ‘Absolutely,’ said Saul. ‘Ted Kaptchuk’s work is all about expanding the definition of placebo beyond a trick pill used in a pharmaceutical trial. He wants to include and quantify the whole therapeutic drama surrounding prescriptions and procedures: the attentive listening, the rituals and the costumes, the diplomas on the wall, the authority of the healer.’

  ‘And being touched,’ said Lucy. ‘The laying on of hands – not in a faith-healer way, but just as an acknowledgement that my body is in need of attention. I’ve spent so much time in hospitals looking at computer images of my brain or talking to a doctor who is reading a printout of some test results. I think that’s one of the appeals of complementary medicine: the acupuncturist and the herbalist take my pulses and look at my tongue and touch my muscles; they are delivering the massive reassurance of dealing directly with my body and not just with my data.’

  ‘Totally,’ said Saul.

  ‘Listen, I must let you have your Capo Santo talk,’ said Lucy, be
ginning to sit up in the hammock.

  ‘You don’t have to go anywhere,’ said Hunter. ‘I’m going to lay my hands on you,’ he said, gently easing her back into a lying position, ‘now I know how much you like that.’

  ‘Why, Doctor, I feel inexplicably well,’ said Lucy, as she subsided into the hammock.

  ‘We call it personal haptic gap closure therapy, or PHGCT,’ said Hunter sagely.

  ‘I feel so lucky to be involved in this trial,’ said Lucy. ‘I hope there are some vaguely similar people in vaguely similar circumstances who are not receiving PHGCT as a control.’

  ‘Don’t worry, Lucy, this is an experiment structured to the most rigorous standards.’

  Lucy smiled at Hunter, who rested his hand fondly for a moment on her tummy before turning to Saul.

  ‘So, where are we with The Inquisition?’ he asked.

  ‘They want fifty per cent,’ said Saul.

  ‘And I want to be non-executive Pope, with fifty per cent of global revenues,’ said Hunter.

  ‘I offered them ten per cent,’ said Saul.

  ‘And?’ said Hunter.

  ‘Holy indignation,’ said Saul.

  ‘Go up to fifteen in exchange for a vigorous advertising campaign, and twenty if they also market the Equanimity helmet, which we can rebrand for them without changing the algorithm: The Peace that Passeth Understanding, Blessed Mother of Tranquillity, whatever works for them.’

  ‘Father Guido told me they were having problems with their Stations of the Cross virtual reality program,’ said Lucy. ‘He became quite confessional over lunch. I think he thought the Espresso Martinis were just iced coffee, but in any case, please don’t do anything to get him into trouble; he’s such a sweet man.’

  ‘We’ll say that the only reason we’re considering profit sharing is thanks to his superhuman negotiating skills,’ said Hunter.

  ‘With Avatar, we’ve got the technology to help with that,’ said Saul.

  ‘No more profit sharing,’ said Hunter. ‘This techno-religion is going to be huge.’

  ‘How about less profit share and we fix the Stations?’ asked Saul.

  ‘That could work,’ said Hunter.

  ‘The beautiful thing is that whether it’s the Bhagavad Gita, or Golgotha, or Mara v Buddha under the Bodhi Tree, we can totally nail the journey with a combination of the scans we’ve already made and the VR from Avatar – which, by the way, turns out to be helping with the schizophrenics they designed it for.’

  ‘Yes, I was happy to see that,’ said Lucy. ‘I mentioned the good results to Martin Carr last week, Olivia’s dad, and he thought that exposing patients who are radically confused about what is real to an experience which is designed to seduce even the most robust realist might not be what is making them feel better.’

  ‘Maybe it helps precisely because it’s a known unreality,’ said Saul.

  ‘I ran the same sort of argument past Martin, but he was sceptical that the beneficial effects were taking place at that kind of cognitive level. He’s worked for years with paranoid schizophrenics and knows that if one of them, for instance, is terrified of getting on to a crowded train, that taking them into a basement, attaching heavy equipment to their heads and inducing hallucinations of simulated train passengers could easily be experienced by them as a satanic ritual designed to drive them mad.’

  ‘So, why the good results?’

  ‘Because often these patients have been so maltreated and are so frightened that being taken seriously, treated sympathetically, told there is a solution, looked after by experts, encouraged to share their responses, and so on, has a strong salutary effect.’

  ‘Another placebo,’ said Hunter.

  ‘Yes,’ said Lucy, ‘in the widest sense that we were talking about earlier: being cared for by people who know what they are doing. Once that trust is established, then all sorts of other things might come into play: the simulation could act as a way to externalise an inner voice, to place it in a narrative, letting out the evil element and projecting it safely.’

  ‘You’ve got to nail this Open Placebo thing,’ said Hunter.

  ‘I’m on it,’ said Saul.

  ‘I’m in it,’ said Lucy.

  ‘How about the known benefits of an early lunch, before Saul leaves for the airport?’

  ‘Perfect,’ said Lucy, swinging out of the hammock with a sense of gratitude at being looked after so well and at the same time with a bruise of sadness about the cloud encircling this peak of kindness and goodwill in her life.

  16

  For Lizzie, it was a cause for unalloyed celebration when Olivia told them that she and Francis were going to have a baby. She loved Francis, looked forward to having a grandchild, and felt that Olivia’s desire to bring a child into the world, despite knowing that she had been an unwanted child at birth, was a deep reparation of her troubled history. For Martin, who had seen Sebastian earlier that day, there were dimensions to the situation, beyond his genuine delight, that he couldn’t discuss with anyone around the table, or even fully appreciate himself, in the atmosphere of jubilation that followed Olivia’s announcement. She had chosen to have the baby at the Royal Free, just up the road from her parents’ house, and had gone on to ask if she and Francis could stay for a while at Belsize Park during the first days of its life. Martin’s need to disguise the disorienting suspicion that his most disturbed patient, who came to the house three times a week, might well be his grandchild’s uncle had prevented him from thinking clearly about the implications at the time.

  Olivia had now set off to Howorth and Martin was able to retreat to the sanctuary of his consulting room fifty minutes before his first patient arrived. Sitting in his worn armchair, staring at the mid-summer garden, he couldn’t stop thinking about Sebastian’s tendency to burst outside in moments of high tension, nor could he shake off the memory of Charlie and Olivia tottering around that same garden as small children or resting there, after being wheeled back and forth across the lawn until they fell asleep in their big old pram – which Lizzie was proud not to have thrown away, all those years ago, despite the children’s slightly anxious mockery of her sentimentality (who was she keeping it for?) and the memorable struggle of hoisting it sideways into the loft. The collision of these two images recurred several times while Martin got up to make a cup of coffee, standing at the back of the room by the cupboard where he kept a small fridge, a kettle and some biscuits, hidden from his hungry patients.

  At least in January he could keep the garden door locked and, in any case, Olivia’s newborn baby was unlikely to go out there during those cold, dark days. Nevertheless, Olivia might naturally wander out on a sunny morning to get some fresh air in that fashionable and elusive enclosure, ‘a safe space’, only to find that her unknown twin was bellowing psychotically in the basement or crouched behind the curtains in a knot of primal fear. Martin’s other patients would lie down, free associating while they gazed at the ceiling, or perhaps closed their eyes, indifferent to the muffled sounds of domesticity that reached his consulting room: the rare, faint ring of the landline or the distant thud of the front door closing, only just audible in a pause. They would probably not notice anyone in the garden, or remark on it if they did, but for Sebastian, who often got up from his chair, or checked over his shoulder, nothing could be more provocative than an infant in its mother’s loving arms. At this stage of his treatment, the sound of Olivia’s baby crying might make him think he was hearing another delusional voice or being tortured by the sly, knowing soundtrack to his screaming psyche. Even if he were well enough by January to be sure that the baby was in fact a baby, he might not be able to stand the competition of seeing it being loved and looked after.

  Martin’s growing conviction that Sebastian was Olivia’s twin brother came from the strange harmonies between some of the material that he brought with him to the sessions and the stories Karen had told Olivia about her brother’s early life. Towards the end of a session that appeared to be a long an
d rather generic allegory of explosive rage and potential attack – ‘where they keep the bombs hidden … the guns and the bodies riddled with bullet holes…’ – Sebastian revealed that when he was eighteen the Tanners had told him that he was an adopted child, but had refused to tell him anything about his mother, except to say that she was a bad woman who hadn’t wanted him, and that she lived in ‘the Arsenal area’. They said that if he was mad enough to want to meet her, he must do it on his own. The mysterious weapons depot and the ‘Gunners’ in Sebastian’s free association turned out not to be entirely metaphorical references, but historical and geographical ones as well. Martin knew that Karen lived in Arsenal; he also knew that Sebastian was the same age as Olivia; although his exact birthday still hadn’t yet come up, he knew it was in the same month as Olivia’s; he knew about the cigarette burns, now transformed into bullet wounds, and he knew that Olivia’s twin had been handed over for adoption at the same age as Sebastian. The evidence was hammering at the door, but Martin had still resisted making any official enquiries about Sebastian’s identity, preferring to work with the material that Sebastian brought to the sessions, keeping it sealed in the alembic of the psychoanalytic process. Now he wondered if he should just find out the facts of the case. Was Sebastian Olivia’s twin or not? And yet, knowing that he would never have tried to find out for Sebastian’s benefit, because the official facts would have introduced a foreign vocabulary into the lexicon of symbolic language that they were working to compile together, how could he justify doing that research simply to appease his own curiosity and concern? Part of him also wished he could discuss the matter with Lizzie, but he resisted doing so. She was a psychotherapist, and in theory he was allowed to discuss difficult cases with his colleagues, but she was also his wife and Olivia’s mother. Only absolute confidentiality could ensure that Sebastian’s insights were not tainted with the distrust and confusion that had afflicted him all his life. Ultimately, Martin could turn to the Ethics Committee; although, as a senior analyst, the Ethics Committee usually turned to him.