How Do We Know What is the Best Medicine? From laughter to the limits of biomedical knowledge by Robin Nunn A thesis submitted in conformity with the requirements for the degree of Doctor of Philosophy Graduate Department of The Institute for the History and Philosophy of Science and Technology University of Toronto © Copyright by Robin Nunn 2011 How Do We Know What is the Best Medicine? From laughter to the limits of biomedical knowledge by Robin Nunn PhD Thesis The Institute for the History and Philosophy of Science and Technology University of Toronto 2011 Abstract Medicine has been called a science, as well as an art or a craft, among other terms that express aspects of its practical nature. Medicine is not the abstract pursuit of knowledge. Medical researchers and clinical practitioners aim primarily to help people. As a first approximation then, given its practical focus on the person, the most important question in medicine is: what works? To answer that question, however, we need to understand how we know what works. What are the standards, methods and limits of medical knowledge? That is the central focus and subject of this inquiry: how we know what works in medicine. To explore medical knowledge and its limits, this thesis examines the common notion that laughter is the best medicine. Focusing on laughter ii provides a robust case study of how we know what works in medicine; it also, in part, reveals the thin, perhaps even non-existent, distinction in medicine between empirically-grounded knowledge and intuition. As there is no single academic discipline devoted to laughter in medicine, the first chapter situates and charts the course of this unusual project and explains why inquiry into laughter in medicine matters. In the following chapters, we encounter claims from distinguished sources that laughter and humor are the best medicine. These claims are examined from a variety of perspectives including not only the orthodox view of evidence-based medicine, but also from narrative, evolutionary and complexity views of medicine. The rarely explored serious negative side of laughter is also examined. No view provides a firm foundation for belief in laughter medicine. A general conclusion from this inquiry is that none of the approaches effectively tame the complexity of medical phenomena; indeed each starkly reveals a greater complexity than found at first glance. A narrower conclusion is that providing a basis for claims about laughter in medicine poses its own specific challenges. A third conclusion is that, as things stand, none of the existing approaches seems up to the task of determining whether something such as laughter is the best medicine. iii Acknowledgments PhD students owe much to others. Not just in student loans. We are indebted to everyone who helped us over many years to creep out of the ooze of ignorance onto the sandy shores of academia. We owe our progress to those who instructed us, inspired expansive ideas and deflated overblown ones, pointed to a book that we must read, or brought focus to blurry thinking, suggested that we omit a section even if it took months to write, yes even if it seemed too perfect to discard, which is why it was discarded, and to those who noticed the lowly but nevertheless notably absent page reference in a citation. More specifically, I was lucky to find a visionary PhD committee willing to take on this interdisciplinary project in a scholarly world that so often erects disciplinary barriers. Thanks to my PhD supervisor Paul Thompson: philosophically speaking, Paul has many concerns about the problematic notion of causation. If I say his course on Philosophy of Medicine, taught jointly with Ross Upshur, in any way caused me to begin this work and that he and Ross subsequently caused my work to be much better, or that the Amarone he poured caused anything at all, then I will demonstrate that I didn©t learn a thing from him about causation. So let©s just say there appear to be some constant conjunctions. Thanks to my committee member Ross Upshur: for adding this project to an already packed schedule and offering constant help. He provided the rare combination of philosopher, physician and provocateur. Thanks to my committee member Marga Vicedo: whose interdisciplinary background spanning history and philosophy, and not to iv forget, screenwriting, is ideal for this interdisciplinary thesis. Marga is the perfect conspirator on matters associated with laughter, not only because of her powerful red pen but also because she adds so much joy and laughter to the world. Thank you Michael Cournoyea, Murray Enkin, Claire Letemendia, Pauline Mazumdar and Ronald de Sousa for comments on parts of this project. Thanks Mark, Lois, Alex, Chris, Sophie, Barbara, Doug, Lleoqq and Jenny who had to put up with years of talk about laughter and medicine. Seriously. Special thanks to Catherine who reminded me that it©s just a PhD after all and there are more things than are dreamt of in my philosophy project. As the exemplar of a great teacher who inspires her students to want to be just like her, she provided support and encouragement throughout. Thanks to Jack who exhorted me to be the first one to bring home a PhD but didn©t live long enough to see it, and to Vera, who despite everything else, always remembers to laugh. I am unable to acknowledge the poodle incident. v Contents Abstract................................................................................................................................ii Acknowledgments..............................................................................................................iv 1. Laughter in Medicine.......................................................................................................1 2. Evidence-Based Laughter Medicine..............................................................................31 3. Story-Based Laughter Medicine....................................................................................49 4. That©s Just Anecdotal.....................................................................................................72 5. Language of Laughter....................................................................................................97 6. If Laughter Is A Placebo, How Can We Know?..........................................................113 7. Serious Laughter..........................................................................................................147 8. Does Evolutionary Medicine Say Laughter is the Best? ............................................164 9. Limits and Laughter.....................................................................................................198 10. Laughterword.............................................................................................................230 vi 1. Laughter in Medicine This project examines laughter in medicine as a means of exploring medical knowledge and its limits more generally. Laughter plays a large role in medicine, appearing not just as therapy but everywhere from doctors© offices to hospitals to medical schools (Robinson 1977). Consequently, laughter can be considered a proxy for medical customs and interventions that we don©t know much about, many of which are not even deemed to be biomedical, but are nevertheless used by most people throughout the world. Laughter has also been taken seriously as something that works in medicine. When Norman Cousins (1976) famously reported that he had cured himself of a debilitating disease using vitamin C and laughter, which he described as "jogging for the innards", he re-energized scientific inquiry into the role of laughter in medicine. If it seems implausible that a patient would abandon orthodox medicine for laughter, it©s important to observe that many patients choose equally implausible unorthodox treatments, such as remote intercessory prayer and homeopathy. Cousins did exactly that for laughter when he abandoned the hospital in which had been receiving treatment and moved into a hotel to treat himself. Although he had no medical training, Cousins projected his ideas even further into the medical mainstream when he secured a faculty position at UCLA medical school. Cousins has also been attacked as a quack and a fraud, not just hailed as a healer ahead of his time. But the popularity of his work stimulated research into laughter, humor and health that continues today. - 1 - Nunn - Best Medicine 2 1.1 From Popular to Scholarly Laughter Far from being a brief guffaw in the recent history of medicine, interest in the role of laughter in medicine and health remains strong. A Google search of the phrase "laughter is the best medicine" returns 2,800,000 links including more than 3000 links to books and nearly 2000 links to videos. Reinforcement of the theme of laughter as medicine starts as early as breakfast: packaging for Quaker Oatmeal offers "Tips for a Happy Heart: Have Fun. Laughter is good medicine." After that meal, or any other, comes a brush with conceptions of laughter from popular science provided by Rembrandt toothpaste advertising: As we continue to make great advances in oral care, sometimes we have to stop and enjoy a good laugh. Laughing releases endorphins, neutrotransmitters that make you feel good. Exposing yourself to the laughter of others can have the same effect. At Rembrandt, we think laughing is essential to a healthy, happy mouth. After all, white teeth don©t matter if there©s nothing to smile about. The laughter bandwagon