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Bad Science: Four Things I Learned From Dr. Ben Goldacre

“You cannot reason people out of positions they didn’t reason themselves into.”

– Ben Goldacre, MD

Dr. Ben Goldacre is the author of the popular Guardian column, Bad Science. He has recently published a book by the same name. Bad Science received a very favorable review from the British Medical Journal and although I was tempted to write my own review for Science Based Medicine, I decided to cherry pick some concepts from the book instead. I hope you’ll enjoy the cherries.

Honesty & Placebos

As you can imagine, any good book about bad science must devote at least one chapter to the concept of placebos. We are all quite familiar with placebos, and how squarely the vast majority (and some would argue all) of complementary and alternative medicines fit into that category.  Ben surprised me with a couple of points that I hadn’t considered previously. Firstly, that alerting patients to the fact that you’re planning to prescribe them a placebo does not necessarily negate its effects, and secondly that no matter how skeptical or intelligent you are – all humans are subject to placebo effects.

Ben references a 1965 study from Johns Hopkins [Park et al., Archives of General Psychiatry] in which patients were explicitly told that they were going to receive a sugar pill (with no medicine in it at all) as treatment for their neuroses. The researchers reported substantial improvements in many of the study subjects’ symptoms.

This is the script that the physicians were to use to explain the placebos to the study subjects:

Mr. Doe… we have a week between now and your next appointment, and we would like to do something to give you some relief from your symptoms. Many different kinds of tranquilizers and similar pills have been used for conditions such as yours, and many of them have helped. Many people with your kind of condition have also been helped by what are sometimes called ‘sugar pills,’ and we feel that a so-called sugar pill may help you too. Do you know what a sugar pill is? A sugar pill is a pill with no medicine in it at all. I think this pill will help you as it has helped so many others. Are you willing to try this pill?

Wow. I was under the impression that the efficacy of the placebo was in the person’s belief that it was a legitimate medicine/therapy. Perhaps it only matters that the prescribing physician believes it might help? Perhaps snake oil salesmen are wasting their time on linguistic and pseudoscientific mental gymnastics?

Of course, the “gymnastics” do help. Other research has shown that the more complex the associated placebo ritual, the more potent its effects (such as piercing the skin with fine needles in many different locations). Nonetheless, I was surprised that an honest and accurate description of a placebo does not necessarily negate its effects.

We’re All Placebo Responders

My second surprise was that no one is immune to placebo effects. My pride wanted to assure me that I was above being hoodwinked, but alas, Ben explained that we humans are all potential placebo responders. Does packaging and marketing language influence your purchase decisions? Then you’re a placebo responder. Ben carefully described the role of packaging and marketing for the cosmetic industry – and I sheepishly had to admit that I have fallen for some of it.

About Liars vs. Bullsh*tters

Placebo peddlers are not necessarily liars. This is a subtle distinction that I hadn’t made before. Ben helped me to understand that alternative medicine practitioners aren’t necessarily offering therapies that they know are outright pseudoscience. Rather,

The liar knows and cares about the truth, but deliberately sets out to mislead; the truth-speaker knows the truth and is trying to give it to us; the bullsh*tter, meanwhile, does not care about the truth, and is simply trying to impress us.

Ben goes on to quote the philosophy professor Harry Frankfurt (from his 1986 essay “On Bullsh*t”):

[The bullsh*tter] is neither on the side of the true nor on the side of the false. His eye is not on the facts at all, as the eyes of the honest man and of the liar are, except insofar as they may be pertinent to his interest in getting away with what he says. He does not care whether the things he says describe reality correctly. He just picks them out, or makes them up, to suit his purpose.

I hope that distinction was helpful to you. I know I’ve mistaken many bullsh*tters for liars in the past. I’ll be glad to label them more correctly in the future. Dr. John is first on my list.

The Prevalence of Woo in Britain vs. the US

My final learning point for this blog post is that, as egregious as American woo is, Britain does seem to be farther along the path to utter surrender to pseudoscience. When I see Sanjay Gupta and Nancy Snyderman teaming up to sell home stool sampling kits for diagnostic purposes, then I’ll know that all hope is lost. Until then, I still feel a sense of pride in the general sensibleness of our medical leaders and spokespeople. Please don’t anyone dissuade me of that potential illusion.

Anyway, you should really pick up a copy of Bad Science to make yourself feel a tiny bit better about US healthcare. Apparently, the school curriculum in Britain encourages children to “massage their carotid arteries through their rib cage” to enhance oxygenation to the brain. Meanwhile, the British government is asking nutritionist Gillian McKeith to advise them on national food policy.  Of course, Gillian says that we should eat more dark green vegetables because their chlorophyll will help us create oxygen for our bloodstream, and that she can sense organ toxicities through a light touch of anyone’s abdomen.

Feel better now, my American friends?

Posted in: Book & movie reviews, Herbs & Supplements, Science and the Media

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20 thoughts on “Bad Science: Four Things I Learned From Dr. Ben Goldacre

  1. misterlizard says:

    Nice review. I certainly enjoyed the book. Things are not *quite* as bad as your last paragraph suggests however. It is only a small (but significant) number of schools carrying out the ludicrous brain gym activities you mention – and it is NOT part of the school curriculum.

    Additionally, it was not the British Government, but the Scottish Government (Scotland being one of the 3 nations that makes up the island of Great Britain and one of the 4 consituent countries of the United Kingdom for accuracy freaks) that *suggested* asking McKeith for assistance – and even then it was only a few Members of the Scottish Parliament – by no means a policy.

    Not that we have any reason to be complacent, after all – we have Prince Charles, – but it not like any of our candidates for governmental high office believe in witchcraft or anything….. :-)

  2. Dr*T says:

    Hi Val,

    Bad Science is indeed a good read!

    Two minor corrections, the BrainGym section is not on the UK school cirriculum (we’re not that bad!), but more that school governors have lacked critical skills when Brain Gym have come round each school touting their unique brand of pseudoscience.

    After Goldacre wrote a number of columns about it, it got discussed in Parliament, to which the minister replied “We do not provide guidance or advice to schools on the use of Brain Gym”, which was an opportunity missed.

    Secondly, I think it was the Scottish Executive (rather than the British government) who dallied with McKeith, but I think even that was eventually dismissed.

    Cheers

    T

  3. gimpyblog says:

    Anyway, you should really pick up a copy of Bad Science to make yourself feel a tiny bit better about US healthcare.

    I’ve always thought the prevalence of woo in Britain was a result of good healthcare being available to all. Unlike the US you do not have to pay money for treatment (minor prescription charges aside) so those who turn to alt-med do so because they have had a bad experience or are unhappy with the realistic suggestions of evidence based healthcare so spend their money on extraordinary claims because they feel evidence based medicine cannot help. In the US for most people there is a choice between paying for evidence based healthcare or paying for alternative medicine, in the UK you get one for free and the other is often a luxury. It’s a case of having your cake and eating it.
    Besides in the US you have a much bigger problem with drug companies making extravagant advertising claims, such direct to consumer advertising is forbidden in the UK – which gives an opening for alternative medicine advertising which is allowed provided it does not make medical claims (although the definition of a medical claim is blurred).

    Apparently, the school curriculum in Britain encourages children to “massage their carotid arteries through their rib cage” to enhance oxygenation to the brain.

    This isn’t strictly true, schools and local authorities have autonomy in funding decisions, the Brain Gym stuff wasn’t part of the curriculum, it was the results of a dubious sales pitch claiming to improve teaching outcomes for a small part of the school’s budget. That’s not to say that alternative nonsense is not on the curriculum, it is for quite a few subjects, and more so in the adult education sector.

  4. anandamide says:

    Ah, Brain Gym – the source of much merriment and despair. It’s a classic pseudoscience, adopting neuroscientific terminology to wow the public before fleecing them for entry into the inner circle, wherein is dispensed a hotchpotch of sensible advice (take regular breaks; kids like doing silly exercises) and complete fantasy. As a bit of friendly transatlantic rivalry, I would point out that the idea originated in the US.

    You might find the following informative, or perhaps simply enjoyable. Colin Blakemore’s amused derision is especially worthwhile.

    http://uk.youtube.com/watch?v=M5rH7kDcFpc

  5. durvit says:

    All of the references for the placebo chapter in Bad Science are listed online (most with links).

    The placebo chapter was interesting yet it might have benefited from a discussion of the Cochrane review that found that there is little evidence to support ‘a large effect for the placebo response’.

    Might I say that as long as you have nutritionists flaunting their Clayton College of Natural Health PhD’s being interviewed with approbation in the NYT (Jonny Bowman’s work triggered a busy discussion), the wonders of Drs Mercola and Weil, the fearless work of Mike Adams, Hulda Clark et al, and the unforgettable “more fluid concept of evidence” being promoted in your leading medical schools by Dr Katz at Yale – we in the Old Country can not hold a candle to the woo entrepreneurship of the US.

  6. Diane Henry says:

    Re: liars v. bulls***ters:
    Although I haven’t read Bad Science yet (still waiting for the library) the description of placebo peddlers as either one or the other doesn’t quite ring true for me. Up here in the Pacific NW, I am surrounded by many alt med “practioners” (and still more believers). Two in my close group of friends are both naturopath/acupuncturists and they are both smart and good people. Just really really deluded people. They don’t think they are lying to their patients–they believe that they are helping people. So if you really really believe that what you are doing is helping people, are you still a bulls****er? We all inhabit self-denial land at one point or another, though most folks don’t make money that way.

  7. Fifi says:

    I have a similar experience to Diane Henry (though I live on the East Coast). I find it problematic when reality isn’t recognized, particularly when it’s in favor of creating simplistic cartoon “evil” to one’s own good. (I actually find it even more problematic when it’s being done by anyone who’s claiming they have a superior grasp of reality since it reveals that their perspective is biased and not taking in the full picture, whichg will lead to conlusions based upon partial observations and evidence.) Painting all alt healers as cartoon evil is also a very good way to turn off a lot of people since many people have experiences with misguided but very genuine and kind alternative healers who in their innocence and ignorance get taught “alternative science” or some woo healing method (which does seem to work to them and their clients as discerned by subjective reporting and observation).

    Certainly there are flat out con artists working in SCAM, particularly in the area of selling products. The same can be said for those whose main motivation is to continually increase profits through selling medicine (whether it’s private clinics, Big Pharma or just an individual doctor who cares more about payments on his BMW than his patient). Plastic surgery is an obvious area of medicine where there is a huge amount of quackery (and it exploits many of the same fears to sell itself). Both active and passive denial are prevalent in medicine too, which further weakens the framing of all people who practice alt med as being corrupt. I don’t see how demonizing people for being human does more than alienate people who don’t assume themselves to be better than other people.

    It seems to me that many, many people engage in some amount of denial at the jobs – most people’s jobs just don’t have the same kind of practical and ethical responsibilities practicing medicine does (nor the kind of power or authority often). All of us engage in some form of denial vis a vis how we live in North America, though I’m sure we all have very tidy little rationalisations for why we’re not in denial but our neighbor is.

  8. Zoo Knudsen says:

    To be fair, your initial quote about reasoning out of a bogus idea originated with Alexander Pope.

  9. wisnij says:

    “Of course, Gillian says that we should eat more dark green vegetables because their chlorophyll will help us create oxygen for our bloodstream”

    Well, at least it’s good advice, even if the rationale is nonsense.

  10. pmoran says:

    On liars vs bullshitters — I suspect that there is frequently a third option in that collusion between patient and practitioner that we call medicine. I think it can involve a state of half-belief, a kind to adult make-believe — something along the lines of “well, it *could* be true — let’s assume so while we see if it will help me with this annoying medical problem.”

  11. pmoran says:

    Re liars vs bullshitters and the use of placebo medicines —

    There has to be more to it than this. Clearly something “clicks” between the public and those offering them dubious medicines.

    I suspect there is the collusion in a kind of half-belief, an adult make-believe if you like, that enables “well, it might be true — let’s assume so while we see if it will help this otherwise unresolved medical need”. The promoter half-believes because it is his living, the patient because they want to feel better.

    An element of make-believe would help explain Wally Sampson’s observations concerning usage vs belief with vitamins.

  12. pmoran says:

    Re: liars and bullshitters and the use of placebo medicines

    There has to be more to it than this. Clearly something “clicks” between the public and those offering them dubious medicines. I suspect that there can be the collusion in a state of half-belief, a kind of adult make-believe if you like, enabling “Well it MIGHT be true — let’s assume so while we find out if it will help me with this unresolved medical problem..” The promoters are kidding themselves because it is their living, the patient because they want to feel better.

  13. pmoran says:

    Re liars and bullshitters and the use of placebo medicines

    There has to be more to it than this. Clearly something “clicks” between the public and those offering them dubious medicines. I suspect that they can collude in a state of half-belief, a kind of adult make-believe if you like, enabling “Well it just MIGHT be true — let’s assume so while we find out if it will help me with this unresolved medical problem.” The promoters keep kidding themselves because it is their living, and it is quite cool to be seen as a “healer”, and the patient because they want to feel better.

    This helps explain Wally Samson’s discovery of the disconnection between the use of vitamins and people’s stated beliefs when asked to think in “science mode” — also the resistance of alt.med beliefs to rational argument — the slightest doubt serves to sustain such a collusion. .

  14. coryblick says:

    Great stuff and thanks for the excellent blog!

    Regarding placebo:

    While the sugar pill may be inert, the interaction was not.

    “Many people with your kind of condition have also been helped by what are sometimes called ’sugar pills,’ and we feel that a so-called sugar pill may help you too.”

    This can provide expectation of a positive outcome.

  15. Sastra says:

    re liars vs. bullshitters:

    I’ve noted that the people I know who use or advocate scientifically implausible forms of alternative medicine are rather quick to resort to the “well, even if it doesn’t really work, why would that matter as long as people feel better?” The fact that any perceived benefit is only a superficial, temporary boost, and normal improvements are misinterpreted or falsely ascribed to the phony remedy, doesn’t seem to bother them — as long as someone, somewhere, feels better and is happy.

    They tell me “if you think you feel better, then you DO feel better.” It doesn’t matter if anything they say about the process or science behind it is actually true. There are a lot of different ways to say that something is true — it can be true “for that person.” In which case, it “worked.” So they figured they’re covered either way.

    I consider that a form of bullshittery hiding behind a short-sighted but genuine concern for people and a smug and rather self-righteous sense of being “flexible.”

  16. hatch_xanadu says:

    Thanks for the cherries! Stockings will be stuffed accordingly.

    I agree with coryblick about the sugar pill script, though; I think it offered far too much encouragement in favor of the pill, and glossed over the part about no medicine at all.

    A clinician telling a patient, particularly a vulnerable psychiatric patient, that he thinks a pill will help is often persuasion enough. That script opened with the premise of “doing something” to relieve symptoms, and also mashed the “helping” of placebos in with the “helping” of tranquilizers. And the “no medicine at all”, if it wasn’t missed entirely by the patients, might have implied some sort of “all natural” remedy. Which, as y’all know, has quite the appeal.

    Also, not everyone understands that “sugar pill” means “fake pill”. Non-clinically oriented people hear and use colloquialisms like “salt tablets” and “water pills” without understanding what exactly that means; I imagine the patients could have thought perhaps there was some therapeutic quality to sugar in pill form.

    I’d like to see that same study repeated with a script that’s not so wheedle-y. I have a feeling the results would be similar, but of course there’s no way to know unless one is using *good* science.

  17. Jurjen S. says:

    Sastra, I don’t the claim “if you think you feel better, then you DO feel better” is such a stretch. Where the disconnect lies is in the implication that if you feel better, you are better.

  18. Honesty says:

    Nutritional medicine, and proved and trialled herbal medicines are both based on scientific analysis beyond the ‘placebo effect’. These are considered ‘alternative’ even if they are very effective and very safe; as well as being well-tolerated/accepted and without side-effects; – especially if the advice or substance involved is non-patentable or outside commercial allopathy.
    I assume that the placebo effect is about:
    1) the individual nature of patients,
    2) the multifactorial nature of scientific human health, { eg. random example: do tests involving heart drugs factor in the results of several trials that show that eating a ‘handful of nuts per week’ reduces heart problems by about 30% ?}
    3) the part of medicine which is not easily studied, or encompassed by science.
    {Such as faith; healing which may be designated as ‘spiritual/faith’ or may be gentle or may include enjoying a more natural environment according to our evolution; personal security, care; the psychological or physical effect of human or animal kindness and compassion; belief, emotional factors such as the need for validation, attention, contact ; mental and ‘spiritual’ elements; etc.}. If this reason plays an important part then surely safety is most relevant.
    4) an other anomolies, changes, or circumstances known or otherwise.

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