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Tribalism and Medical Ethics

Science is intended to discover the “is”, not the “ought;” facts, not values. Science can’t tell us whether an action is moral; it can only provide evidence to help inform moral decisions. For instance, some people who believe abortion is immoral reject birth control methods that prevent implantation of a fertilized ovum on the grounds that it constitutes abortion; science can determine that a particular birth control method prevents fertilization rather than preventing implantation of a fertilized ovum. A new book, Moral Tribes: Emotion, Reason, and the Gap Between Us and Them, by Joshua Greene, provides some intriguing insights that are pertinent to medical ethics.

He thinks tribalism is the central tragedy of modern life. Evolution equipped us for cooperation within our own tribe but not for cooperation with other tribes. Cooperation with related individuals helps spread our own genes, but we are in competition with other tribes and cooperating with them might help spread their genes to the detriment of our own. It boils down to Us vs. Me and Us vs. Them. He uses the word “tribes” not in the original sense (Hutus vs. Tutsis), but to include Democrats vs. Republicans, Catholics vs. Protestants, CAM vs. science-based medicine, Arabs vs. Israelis, climate change activists vs. climate change deniers, and any other ideological or nationalistic group. (more…)

Posted in: Book & movie reviews, Critical Thinking, Evolution, Medical Ethics

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Vitamin E for Alzheimer’s

Recently you may have seen headlines like “Vitamin E slows decline in patients with mild Alzheimer’s” or “There’s still no cure for Alzheimer’s disease, but the latest hope for slowing its progression is already on drugstore shelves.” They were referring to an article in the January 1, 2014 issue of the Journal of the American Medical Association (JAMA) announcing the results of the TEAM-AD VA Cooperative Randomized Trial of vitamin E and memantine (Namenda) for Alzheimer’s disease (AD).

The study attracted a lot of media attention. Most of the news reports I have seen were accurate and cautious, explaining the nuances of the study rather than suggesting that everyone should run out and buy vitamin E; but I wouldn’t be surprised to learn that a lot of readers ignored the fine print and did just that. It would be interesting to track sales of vitamin E and see if there was a bump following the publicity.

We know of no treatment that will delay, prevent or cure Alzheimer’s disease, or that affects the underlying disease process. It’s a tragic, frustrating disease that takes away the very things that make us who we are: memory and personality. It is affecting more and more people as the numbers of elderly increase. Available prescription medications are only modestly effective in slowing functional decline and delaying the need for institutionalization. They are expensive, they don’t help everyone, and when they do help, they only help for a limited time. It is very exciting to think an inexpensive vitamin could help patients with mild to moderate AD, but we must resist the temptation to read too much into this study. (more…)

Posted in: Clinical Trials, Herbs & Supplements, Neuroscience/Mental Health

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Doctors Are Not “Only Out to Make Money”

There’s an old joke about the doctor whose son graduates from medical school and joins his practice. After a while the son tells his father, “You know old Mrs. Jones? You’ve been treating her rash for years and she never got better. I prescribed a new steroid cream and her rash is gone!” The father responds, “You idiot! That rash put you through medical school.”

That’s a joke. It doesn’t reflect reality, but it reinforces a common misconception that doctors care more about their own income than about their patient’s outcome. That accusation is demonstrably untrue.

I’m sick and tired of all the doctor-bashing. They accuse us of being shills for Big Pharma. They say “Doctors are only out to make money.” Or “Doctors are greedy bastards only interested in the bottom line.” Or as one of our commenters recently put it: “First do no harm. Second ? Third, profit [sic]” Some have even made the ridiculous accusation that doctors have found the cure for cancer but have suppressed the information so as to keep people sick and increase their business. If profit were really their primary motivation, doctors would have to be astoundingly clueless, because they keep doing things that are guaranteed to reduce their profits. (more…)

Posted in: Science and Medicine

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Garcinia Probably Works But Is Far From a Weight Loss Miracle

Women make up a majority of Dr. Oz’s audience. The majority of women would like to lose weight. That is a match made in heaven, a marketer’s dream. And Oz has never hesitated to exploit that fact to increase audience share, playing fast and loose with sensationalized evidence instead of giving his viewers science-based advice.Garcinia

Dr. Oz has promoted a series of weight loss supplements on his show. Raspberry ketones were presented as a fat-busting miracle, then green coffee bean extract was touted as “magic,” “staggering,” and “unprecedented.” And now both of those miracles have apparently been superseded by an even greater miracle: Garcinia cambogia extract.

Dr. Oz calls it “The newest, fastest fat buster.” A way to lose weight without “spending every waking moment exercising and dieting.” “Triples your weight loss.” “The most exciting breakthrough in natural weight loss to date.” “The Holy Grail.” Oz claims that “Revolutionary new research says it could be the magic ingredient that lets you lose weight without diet or exercise.” That sounds too good to be true, and it is. Garcinia probably does work to some extent to improve weight loss, but the evidence doesn’t begin to justify such grandiose claims. (more…)

Posted in: Herbs & Supplements, Science and the Media

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And Now for Something Completely Different

This will be a departure from my usual posts. Several announcements in the news and medical journals have caught my attention recently, and as I delved into the details, I thought I would share them with our SBM readers. Topics include AIDS cures, the continuing danger of polio, eating nuts for longevity, racial differences in vitamin D, and the use of pharmacogenetic testing to guide the dosage of anticoagulant drugs. They are all examples of science-based medicine in action.

Have patients been cured of AIDS?

I read that the HIV virus had returned in patients thought to have been cured by bone marrow transplants, and I mistakenly thought they were referring to the original claim of cure I had read about. Nope, that one still stands. (more…)

Posted in: Clinical Trials, Nutrition, Pharmaceuticals, Vaccines

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Chiropractic Reform: Myth or Reality?

The recent uproar about the chiropractor who was accused of breaking an infant’s neck has provoked renewed discussions about the role of chiropractors, not only in the care of children, but in general. We have addressed chiropractic many times on this blog. While spinal manipulation therapy (SMT) is an effective option for treating certain types of low back pain, chiropractors typically do a lot of other things that are not evidence-based, can be dangerous (strokes from neck manipulation), and are often outright quackery like applied kinesiology. Chiropractic treatment of children has been called child abuse, and even some chiropractors have spoken out against it.

Chiropractors have protested in the comment threads that we have an outdated, biased view of chiropractic, and that modern chiropractic practice is very different. They claim that they have rejected the original basis of chiropractic (the subluxation/nerve interference/innate paradigm), that they reject all forms of quackery, that what they do is based on scientific evidence, and that they have an important role to play in modern health care. We think that “reformed” attitude is rare. We would love to know what percentage of chiropractors fall into the “reformed” category, but no studies have been done to answer that question. Now there is a new study from Australia that provides important information about the state of chiropractic practice in that country. While it can’t answer the question about the number of “reformed” chiropractors in the US, it does shed some light on the subject. (more…)

Posted in: Chiropractic

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Philosophy Meets Medicine

Note: This was written as a book review for Skeptical Inquirer magazine and will be published in its Jan/Feb 2014 issue.

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Medicine is chock-full of philosophy and doesn’t know it.  Mario Bunge, a philosopher, physicist, and CSI (Center for Skeptical Inquiry) fellow, wants to bring philosophy and medicine together for mutual benefit. He has written a book full of insight and wisdom, Medical Philosophy: Conceptual Issues in Medicine.

Whether doctors recognize it or not, medicine is firmly based on the philosophical principles of materialism, systemism, realism, scientism, and humanism. Bunge explains that:

Without materialism, both diseases and therapies would be taken to be purely spiritual.

Without systemism, every disease would be attributed to an independent module.

Without realism, diseases would be viewed as either imaginary or as social flaws.

Without scientism, either nihilism or dogmatism would prevail, and all the achievements of biomedical research of the last 500 years would be consigned to oblivion.

Without humanism, all medical practice would be mercenary, and there would be no public health care. (more…)

Posted in: Book & movie reviews

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New Cholesterol Guidelines

On November 15, the American College of Cardiology and the American Heart Association released an updated guideline for the use of statins to prevent and treat atherosclerotic cardiovascular disease (ASCVD). The full report is available online. It has already generated a lot of controversy. The news media have characterized it as a “huge departure” from previous practice and have trumpeted that it will lead doctors to prescribe statins to millions more people. As usual, the truth is much more nuanced. There are some problems with the guidelines, but on the whole they represent an improved, more rational approach to prescribing statins.

Statins have always been a source of controversy: people seem to either love them or hate them, and discussions about them generate a lot of emotion. The International Network of Cholesterol Skeptics denies that cholesterol has anything to do with cardiovascular disease. An article on HuffPo calls statins “an unsafe, unnecessary product that will now be recommended to healthy people to make them sicker.” Mercola says they can actually make heart disease worse and cause premature aging, and no one should take them unless they have the genetic defect of familial hypercholesterolemia. A website collects patient self-reports of adverse effects; but like the vaccine reports on VAERS, these are only anecdotal reports of correlation, not evidence for causation.

At one time the evidence only supported using statins for secondary prevention and for men. We now have better evidence showing that they are effective for both primary and secondary prevention in patients of both sexes and all ages, and that they are more effective for those with higher risk factors. (more…)

Posted in: Pharmaceuticals

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Faith Healing: Religious Freedom vs. Child Protection

We have written a lot about people who reject science-based medicine and turn to complementary/alternative medicine (CAM), but what about people who reject the very idea of medical treatment?

Faith healing is widely practiced by Christian Scientists, Pentecostalists, the Church of the First Born, the Followers of Christ, and myriad smaller sects. Many of these believers reject all medical treatment in favor of prayer, anointing with oils, and sometimes exorcisms. Some even deny the reality of illness. When they reject medical treatment for their children, they may be guilty of negligence and homicide. Until recently, religious shield laws have protected them from prosecution; but the laws are changing, as are public attitudes. Freedom of religion has come into conflict with the duty of society to protect children. The right to believe does not extend to the right to endanger the lives of children. A new book by Cameron Stauth, In the Name of God: The True Story of the Fight to Save Children from Faith-Healing Homicide, provides the chilling details of the struggle. He is a master storyteller; the book grabs the reader’s attention like a fictional thriller and is hard to put down. He is sympathetic to both the perpetrators and the prosecutors of religion-motivated child abuse, and he makes their personalities and their struggles come alive. (more…)

Posted in: Book & movie reviews, Faith Healing & Spirituality, Politics and Regulation

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Colonoscopy and Other Colorectal Cancer Screening Options: An Update

When I wrote about colonoscopy in 2010, colonoscopy was thought to be the best screening test for colorectal cancer because it could visualize the entire colon and could remove adenomas that were precursors of cancer. But only fecal occult blood testing (FOBT) and sigmoidoscopy had been proven to decrease colorectal cancer incidence and mortality (by 16% and 28%, respectively). Observational evidence suggested that colonoscopy would reduce the incidence and the number of deaths from colorectal cancer, but there were no randomized controlled trials, and the reduction in incidence of cancer after colonoscopy screening seemed to be restricted to left-sided colon cancers, which didn’t make sense.

We still don’t have any randomized controlled trials of colonoscopy, but a 2013 case-control study from Germany compared patients with and without colorectal cancer and found that those who reported having had a colonoscopy were less likely to develop colon cancer for up to 10 years after the procedure. And now two studies published in the New England Journal of Medicine in September 2013 have shed more light on the subject.
(more…)

Posted in: Cancer, Diagnostic tests & procedures

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