Chekhov is best known as a great writer of short stories. But he was also a doctor and wrote many tales of medicine and doctors in everyday life.
But recently, again, I have seen homeopaths claim that Chekhov “used [homeopathy] and swore by its curative effects”. No doubt, the source for such claims come from the American homeopathy entrepreneur, Dana Ullman. His book, The Homeopathic Revolution, Why Famous People and Cultural Heroes Choose Homeopathy, is full of claims of support for homeopathy where often this is highly dubious. (We have already extensively dismissed his attempts to co-opt people such as Charles Darwin and Florence Nightingale as a believer in homeopathy).
In his book, Ullman starts by undermining his own case that Chekhov was a “literary great who advocated for homeopathy” by saying,
We must be thankful that he wasn’t a homeopath because the joys and the benefits from homeopathic practice might have led him to forego his magnificent contributions to literature.
Nonetheless, Chekhov managed to combine the joys and benefits of being a real doctor with his literary career.
It would appear that homeopaths believe Chekhov was an advocate of homeopathy merely because he wrote about it, most significantly in his short story, Malingerers. Indeed, if you just read the first two-thirds, you may feel that Chekhov had sympathies to the beliefs of homeopaths. But the title of the short story ought to be a clue that it is not as simple as that.
In fact, the story shines light on a crucial aspect of why people can believe inert medicines work and he provides an interesting twist on the placebo effect. It is probably worth reading the whole story before we discuss its implications. It is short and well worth it.
MARFA PETROVNA PETCHONKIN, the General’s widow, who has been practising for ten years as a homeopathic doctor, is seeing patients in her study on one of the Tuesdays in May. On the table before her lie a chest of homeopathic drugs, a book on homeopathy, and bills from a homeopathic chemist. On the wall the letters from some Petersburg homeopath, in Marfa Petrovna’s opinion a very celebrated and great man, hang under glass in a gilt frame, and there also is a portrait of Father Aristark, to whom the lady owes her salvation — that is, the renunciation of pernicious allopathy and the knowledge of the truth. In the vestibule patients are sitting waiting, for the most part peasants. All but two or three of them are barefoot, as the lady has given orders that their ill-smelling boots are to be left in the yard.
Marfa Petrovna has already seen ten patients when she calls the eleventh: “Gavrila Gruzd!”
The door opens and instead of Gavrila Gruzd, Zamuhrishen, a neighbouring landowner who has sunk into poverty, a little old man with sour eyes, and with a gentleman’s cap under his arm, walks into the room. He puts down his stick in the corner, goes up to the lady, and without a word drops on one knee before her.
“What are you about, Kuzma Kuzmitch?” cries the lady in horror, flushing crimson. “For goodness sake!”
“While I live I will not rise,” says Zamuhrishen, bending over her hand. “Let all the world see my homage on my knees, our guardian angel, benefactress of the human race! Let them! Before the good fairy who has given me life, guided me into the path of truth, and enlightened my scepticism I am ready not merely to kneel but to pass through fire, our miraculous healer, mother of the orphan and the widowed! I have recovered. I am a new man, enchantress!”
“I… I am very glad…” mutters the lady, flushing with pleasure. “It’s so pleasant to hear that… Sit down please! Why, you were so seriously ill that Tuesday.”
“Yes indeed, how ill I was! It’s awful to recall it,” says Zamuhrishen, taking a seat. “I had rheumatism in every part and every organ. I have been in misery for eight years, I’ve had no rest from it… by day or by night, my benefactress. I have consulted doctors, and I went to professors at Kazan; I have tried all sorts of mud-baths, and drunk waters, and goodness knows what I haven’t tried! I have wasted all my substance on doctors, my beautiful lady. The doctors did me nothing but harm. They drove the disease inwards. Drive in, that they did, but to drive out was beyond their science. All they care about is their fees, the brigands; but as for the benefit of humanity — for that they don’t care a straw. They prescribe some quackery, and you have to drink it. Assassins, that’s the only word for them. If it hadn’t been for you, our angel, I should have been in the grave by now! I went home from you that Tuesday, looked at the pilules that you gave me then, and wondered what good there could be in them. Was it possible that those little grains, scarcely visible, could cure my immense, long-standing disease? That’s what I thought — unbeliever that I was! — and I smiled; but when I took the pilule — it was instantaneous! It was as though I had not been ill, or as though it had been lifted off me. My wife looked at me with her eyes starting out of her head and couldn’t believe it. ‘Why, is it you, Kolya?’ ‘Yes, it is I,’ I said. And we knelt down together before the ikon, and fell to praying for our angel: ‘Send her, O Lord, all that we are feeling!’”
Zamuhrishen wipes his eyes with his sleeve gets up from his chair, and shows a disposition to drop on one knee again; but the lady checks him and makes him sit down.
“It’s not me you must thank,” she says, blushing with excitement and looking enthusiastically at the portrait of Father Aristark. “It’s not my doing…. I am only the obedient instrument.. It’s really a miracle. Rheumatism of eight years’ standing by one pilule of scrofuloso!”
“Excuse me, you were so kind as to give me three pilules. One I took at dinner and the effect was instantaneous! Another in the evening, and the third next day; and since then not a touch! Not a twinge anywhere! And you know I thought I was dying, I had written to Moscow for my son to come! The Lord has given you wisdom, our lady of healing! Now I am walking, and feel as though I were in Paradise. The Tuesday I came to you I was hobbling, and now I am ready to run after a hare…. I could live for a hundred years. There’s only one trouble, our lack of means. I’m well now, but what’s the use of health if there’s nothing to live on? Poverty weighs on me worse than illness…. For example, take this… It’s the time to sow oats, and how is one to sow it if one has no seed? I ought to buy it, but the money… everyone knows how we are off for money….”
“I will give you oats, Kuzma Kuzmitch…. Sit down, sit down. You have so delighted me, you have given me so much pleasure that it’s not you but I that should say thank you!”
“You are our joy! That the Lord should create such goodness! Rejoice, Madam, looking at your good deeds!… While we sinners have no cause for rejoicing in ourselves…. We are paltry, poor-spirited, useless people… a mean lot…. We are only gentry in name, but in a material sense we are the same as peasants, only worse…. We live in stone houses, but it’s a mere make-believe… for the roof leaks. And there is no money to buy wood to mend it with.”
“I’ll give you the wood, Kuzma Kuzmitch.”
Zamuhrishen asks for and gets a cow too, a letter of recommendation for his daughter whom he wants to send to a boarding school, and… touched by the lady’s liberality he whimpers with excess of feeling, twists his mouth, and feels in his pocket for his handkerchief….
Marfa Petrovna sees a red paper slip out of his pocket with his handkerchief and fall noiselessly to the floor.
“I shall never forget it to all eternity…” he mutters, “and I shall make my children and my grandchildren remember it… from generation to generation. ‘See, children,’ I shall say, ‘who has saved me from the grave, who. ..’”
When she has seen her patient out, the lady looks for a minute at Father Aristark with eyes full of tears, then turns her caressing, reverent gaze on the drug chest, the books, the bills, the armchair in which the man she had saved from death has just been sitting, and her eyes fall on the paper just dropped by her patient. She picks up the paper, unfolds it, and sees in it three pilules — the very pilules she had given Zamuhrishen the previous Tuesday.
“They are the very ones,” she thinks puzzled. “… The paper is the same…. He hasn’t even unwrapped them! What has he taken then? Strange…. Surely he wouldn’t try to deceive me!”
And for the first time in her ten years of practice a doubt creeps into Marfa Petrovna’s mind…. She summons the other patients, and while talking to them of their complaints notices what has hitherto slipped by her ears unnoticed. The patients, every one of them as though they were in a conspiracy, first belaud her for their miraculous cure, go into raptures over her medical skill, and abuse allopath doctors, then when she is flushed with excitement, begin holding forth on their needs. One asks for a bit of land to plough, another for wood, a third for permission to shoot in her forests, and so on. She looks at the broad, benevolent countenance of Father Aristark who has revealed the truth to her, and a new truth begins gnawing at her heart. An evil oppressive truth….
The deceitfulness of man!
So, Chekhov was obvoiusly not writing a story about the wonders of homeopathy but about how one homeopath started to doubt the effectiveness of her sugar pills after discovering her patients mislead her.
It’s an example of the effects of placebo. Placebo effects do not just mislead patients, but also practitioners. And this story highlights very well that placebos can give rise to the appearance of effective treatments without any actual healing having taken place. This is an important point in understanding placebos. It is a common misrepresentation to say that placebo effects are about mind-body interactions actually changing the course of an illness for the better.
Indeed, apologists for homeopathy, such as the new leader of the Green Party, make this mistake. Nathalie Bennett commented on homeopathy,
We know the placebo effect is very powerful, and may in fact be the best treatment for some patients with some conditions, but the doctor can’t say “I’m prescribing a placebo”.
So that’s how homeopathy works, and if it is used through the NHS, it does mean people have been checked for cancer etc first.
Is the placebo effect ‘powerful’? Or more specifically, can it actually make a difference to the course of disease? The evidence for this is very poor.
Systematic reviews by Hróbjartsson & Götzsche suggest that there is little evidence that placebos can produce objective results (e.g. reducing death). They looked at studies where a placebo and a ‘no treatment’ group were included and concluded there was “little evidence in general that placebos had powerful clinical effects”. When subjective effects were looked at (e.g. experience of pain), there was a “possible small effect from patient-reported outcomes. ” The results were even less for observer-reported outcomes and results could not be clearly distinguished from bias.
Of course, subjective improvements can represent real benefits to patients. But not always. We need to be careful that we are not witnessing placebo effects arising from various biases and ways of misreporting outcomes.
The Chekhovian placebo response is a good example of where subjective, patient-reported outcomes mislead an observer into thinking a treatment is effective. One may think it is outlandish to think we can explain homeopathy because their patients are trying to gain favour in order to seek other benefits. But such scenarious are not ridiculous.
Indeed, placebo effects may arise from the natural human desire to reciprocate good deeds. A patient may report improvements are greater,or have been achieved earlier, in order to please their therapist. A homeopathy may provide a much longer and more empathic consultation that a GP. There will be a natural desire to return that perceived kindness, even if that is done subconsciously. A homeopath may well base a career on the kind words of their clients who bother to come back and report results. It does not require Marfa Petrovna’s deceitful malingerers in order to be fooled by such reports.
But in reporting good results, patients may also be seeking extra benefits for themselves. If you have been following the stories of how UK patients are going to a highly dubious cancer clinic in Texas to receive unproven and questionable treatments for brain tumours, you may well be aware of recent patient blogs of how Dr Burzynski has been telling them they are cancer free (here and here) when their UK oncologists are being much more circumspect.
Telling a patient that they are cancer free at such a stage in their treatment is not just wrong but evil. Given the regime of surgery and drug treatments, it is quite possible that an MRI scan may show little signs of cancerous growth. But that does not mean the cancer is not still there. Telling someone they are cancer free simply will provide Dr Burzynski with more blog and video testimonials of the greatness of his treatments. For patients, the psychological gains to be had in reporting such news are obvious when the alternative is the more doubtful, uncertain and dark views of a real oncologist.
Placebo effects are about changing beliefs and expectations. Those beliefs may be in the patient’s mind. They may be in the practitioner’s mind. Or indeed they even may be in a pet owner’s mind when are talking about animal quackery. Chekhov’s story shows us that it is wrong to see placebo effects as powerful mind-over-body miracles. Placebo effects can be much darker, misleading and dangerous.