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Blog Discussion with an SBM Critic

Over the last couple of days I have been engaged at NeuroLogica in a discussion with a fellow blogger, Marya Zilberberg who blogs at Healthcare, etc. Since the topic of discussion is science-based medicine I thought it appropriate to reproduce my two posts here, which contain links to her posts.

A Post-Modernist Response to Science-Based Medicine

I receive frequent commentary on my public writing, which is great. The feature that most distinguishes blogs is that they are conversations. So I am glad to see that science-based medicine (a term I coined) is getting targeted for criticism in other blogs. One blogger, Marya Zilberberg at Healthcare, etc., has written a series of posts responding to what she thinks is our position at Science-based medicine. What she has done, however, is make many of the logical fallacies typically committed in defense of unscientific medical modalities and framed them as one giant straw man.

She is partly responding to this article of mine on SBM (What’s the harm) in which I make the point that medicine is a risk vs benefit game. Ethical responsible medical practice involves interventions where there is at least the probability of doing more benefit than harm with proper informed consent, so the patient knows what those chances are. Using scientifically dubious treatments, where there is little or no chance of benefit, especially when they are overhyped, is therefore unethical. And further, the “harm” side of the equation needs to include all forms of harm, not just direct physical harm.

Zilberberg’s response is the typical tu quoque logical fallacy — well, science-based medicine is not all it’s cracked up to be either, so there. She writes:

Now, let’s get on to “proof” in science-based medicine. As you well know, while we do have evidence for efficacy and safety of some modalities, many are grandfathered without any science. Even those that are shown to have acceptable efficacy and safety profiles as mandated by the FDA, are arguably (and many do argue) not all that. There is an important concept in clinical science of heterogeneous response to treatment, HTE, which I have addressed extensively on my blog. I did not make it up, it is very real, and it is this phenomenon that makes it difficult to predict how an individual will respond to a particular intervention. This confounds much of what we think is God’s own word on what is supposed to work in allopathic medicine.

This is also the fallacy of the perfect solution — since science-based medicine is not perfect, there is no legitimate basis for criticism of any modality. This is also premised on the false dichotomy of “allopathic medicine” (a derogatory term only used, in my experience, by defenders of dubious medicine) vs “alternative” medicine (which I will refer to as CAM for short). I and others at SBM have been clear that we eschew this false dichotomy. There is only medicine with varying degrees of plausibility and evidence — there is a continuum, and we advocate always using the best that is available. We also think there should be a minimum standard, a fuzzy line of plausibility and evidence below which treatments should only be given with proper informed consent as part of an approved clinical trial. And a further line below which even research is unethical because there is no plausible potential for benefit.

These principles are, in fact, already part of ethical medicine. We did not invent these concepts. It is, rather, the proponents of CAM who wish to do away with this ethical standard — to create a false dichotomy in order to establish a double standard. We are not trying to create a new standard, just to do away with the double standard of CAM.

She refers to the heterogeneous response to treatment, again as if realization of this basic fact is not already part of science-based medicine. I, in fact, explain this to patients all the time. Our knowledge of treatments is based upon statistics, but we can never know ahead of time how an individual patient will respond. What’s the alternative? Until we get better at predicting individual response (which really will just be another application of statistics), this is the best we can do. That is why you monitor the individual response to any treatment, and act accordingly. This is basic medical student stuff, but Zilberberg acts as if this is a big revelation for science-based medicine.

We at SBM advocate for the highest scientific standards of medicine, and apply that across the board — including with pharmaceutical companies, surgeons, and anything else that is labeled as “mainstream.” Again — we do not make false categories and distinctions. It is all medicine.

The reference to “God’s own word” is an obvious allusion to the bad-old-days of paternalistic medicine (dead and buried for decades now), or the TV caricature of a doctor with a God complex. This is a typical ploy — portray any attempt at defending a scientific standard in medicine as paternalistic arrogance. In fact, Zilberberg dedicates an entire blog post to this fallacy. She writes:

First of all, it is my belief that all interventions should be approached with equanimity, if not equipoise. Although I am quite dubious that either healing crystals or Reiki can produce actual results, I do not want to confuse the absence of any evidence to this effect with the evidence of absence of the effect. Although I am not that interested in allocating resources to studying these fields, it would be paternalistic of me to bar their further investigation. So the society can decide what it wants to do with them, and in the meantime every individual can make her/his own choice whether to spend their money on them.

This is clearly where we differ. I do think, from reading her writing, that Zilberberg means well and is sincere in her positions (unlike some I criticize who I feel are just trying to sell something). But notice the logical contortions in her position — she wants “equipoise” with regard to all interventions, and would not dare dictate how research money is spent. I should point out that there is a range of opinions on SBM when it comes to regulation — so we are not a united front on this score. We range from libertarians who think that we should educate the public and professionals, but are against laws that would restrict access to unscientific modalities. Essentially, people have the right to make stupid decisions. Others believe that there needs to be a minimum safety net against fraud and quackery, and in fact the public wants there to be one and believes there already is one. I don’t want to get bogged down in this debate on this blog entry — I am just pointing out that Zilberberg’s premise is overly simplistic and paints with too broad a brush.

But the real point here is that she is taking an almost post-modernist position that we need to approach all claims in medicine with “equipoise.” She says that society can decide how research money is spent, even if she would not personally research an implausible topic. Depending upon how you slice it, this is not necessarily far off from my position. If people want to raise money to research an implausible question they should go right ahead. I never proposed banning implausible research. My position, rather, is that we should not waste limited public/government research resources on highly implausible modalities.

I would also add, however, that once you start doing research on humans there is a host of ethics that also come into play. In human research it is the accepted ethical standard that subjects should at least have a chance of benefiting from the treatments being studied, or at least there should be a greater chance of benefit than harm. I don’t see how this ethical standard can be met with homeopathy, for example, where there is essentially zero chance of benefit. At some point you pass a line of infinitessimal plausibility where the ethics become problematic.

Zilberberg then makes the “absence of evidence vs evidence of absence” mistake — really an oversimplification of this concept to the point of being wrong. While it is true that the absence of evidence if not necessarily evidence of absence — it can be, depending upon how thoroughly you have looked. If I search my house for a specific item and don’t find it, that is pretty good evidence that it’s not there. It is not “proof” of absence, but it is evidence. With many of the modalities that Zilberberg admits she is personally dubious about there is evidence of absence of an effect. This evidence comes in two forms — all of the science that tells us the modalities are highly implausible, and often there is clinical evidence of lack of an effect. To pretend otherwise is dishonest — it is hiding from the facts out of political correctness.

Further, our patients do not want equipoise from us. They want our informed opinion. When patients ask me if they should take a homeopathic remedy I don’t give them a wishy washy answer. I give them my informed opinion, and they are grateful to have it. In the comments to her blog a commenter speculates about my bedside manner, assuming, essentially, that I must be a paternalistic ass. This is the typical cardboard caricature I encounter, and it has no relationship to reality. It is possible to give patients useful information without being judgmental. To give them informed consent (how do you do this, by the way, without giving them information?) but understand that they will make up their own minds. Patients are in charge of their own health care, and our job as clinicians, more than ever, is to give them the information and perspective they need to make good decisions. This does not demand “equipoise”, but evidence and perspective. In my opinion equipoise in the face of ridiculously implausible claims and evidence of lack of efficacy is a disservice to patients and a violation of trust.

Ironically, Zilberberg concludes:

Bottom line, we need to appreciate that none of the science is all that straightforward. Let us not dumb down the arguments and create false dichotomies. If we do, no one wins.

Does she actually read science-based medicine? I am left to wonder — since we regularly argue for the complexity of the science of medicine. I want people to understand how complex the relationship is, so they are not shocked every time conflicting studies come out. Medical science is a messy business, and it is challenging often to infer what the best approach is. I want the profession and the public to have a much more nuanced understanding of medical science, and for the media to do a better job of representing it.

This is especially true since we do not have a paternalistic system. Patients are partners in their own health care, and therefore it helps me do my job when they understand the science that underpins medicine.

Zilberberg’s position is anti-science, although perhaps not deliberately so. It is anti-science in a post-modernist sense. She points out all the limitations of science, as if that means we cannot come to any meaningful decision, and therefore must treat all claims as equal. But all claims are not equal. Even the best are imperfect, but we can still apply science and evidence to make informed decisions about the probability of risk vs benefit. And there are some claims that are so against science and evidence (like homeopathy) that any stance other than rejection is a violation, in my opinion, of medical ethics and the trust that society places in medical professionals.

In Zilberberg’s world, however, any such judgments are the equivalent of pronouncing that these treatments over here in pile A are deemed “scientific” (as if by the word of God) and are accepted. And these over here in pile B are deemed “nonsense” and are to be ridiculed. But the false dichotomy is in her mind, not in science-based medicine. We are the ones railing against the false dichotomy — that of CAM which seeks to create a double standard. All we advocate is one consistent standard of science and evidence when evaluating all medical claims, and the rational application of science to the practice of medicine.

One final note — I would much prefer to have a conversation with the critics of science-based medicine that does not constantly involve defending SBM and myself from false accusations of arrogance and paternalism. I think it says a lot about their intellectual position when that is constantly the best they have.

Dr. Zilberberg Responds

Dr. Zilberberg responded to my original post and significantly modified her tone, to her credit. (She was simultaneously responding to Orac’s analysis of her posts as well.) Here is my analysis of that post.

The Tone Thing

I will address her main points below, but first my final thoughts on the “tone” thing. While she admits fault in setting the “confrontational tone,” I don’t think she quite gets what Orac and I were objecting to. I actually don’t mind a confrontational approach — as long as it is substantive (that’s the way science works — if you have a point to make, bring it on). We were objecting to her mischaracterizing our position and making ad hominem attacks in place of substantive criticism — essentially using the “arrogant” gambit with which we are all too familiar. Her readers obviously picked up on this, and piled one, accusing us of being bullies and thanking her for slapping us down. We objected to her logical fallacies, not her tone.

Interestingly Zilberberg’s initial response was dismissive, and she reiterated the charge of paternalism and arrogance, writing: “If the shoe fits?” At least now she seems to realize that if we are going to have a productive discussion, focusing on ad hominem attacks will be counterproductive.

Incidentally, having written about medicine for years I have definitely seen a strong pattern. When I criticize the logic and factual premises of another person’s argument I am frequently accused of being mean by people who then attack me personally. It seems many people do not understand the difference between a strong but substantive criticism and a personal attack. Zilberberg was falling into this category, but has significantly (if incompletely) backed off from that with her latest post.

One more minor point — “allopathic” is derogatory and does not apply to modern medicine (it was coined by Samuel Hahneman to refer to the poisons that passed for medicine in his time, and was definitely meant to be a criticism). I would suggest she drop this term rather than defend it.

Evidence in Medicine

Zilberberg then launches into a meaty discussion of what her position actually is. She observes that perhaps we are not that far off in our positions, which I think is true. There is a meaningful difference in spin — the final conclusions drawn from the analysis, but her analysis of the role of evidence in medicine is reasonable. But again, to clarify, Orac and I were not objecting to the point that evidence in medicine is messy and complex. We were objecting to the accusation that we do not understand this, and that we are promoting an overly simplistic and cheerleading approach to science in medicine. This left me with the impression that Zilberberg has not read deeply into the Science-Based Medicine website, or at least has failed to grasp what it is we are actually saying.

If she had she would have seen post after post in which SBM authors were pointing out all of the complexities and deficiencies of evidence in medicine that she and others might also point to. That is core to the point of SBM — evidence is complex. She might, in fact, have read my series of posts on evidence in medicine. We do spend a great deal of time pointing this out in the context of so-called CAM, because CAM proponents are the ones who most profoundly take a simplistic approach to the evidence. They engage in black-and-white thinking, display intolerance of ambiguity, and frequently advocate for the reliance on very problematic low-grade evidence to support their claims. But we also consistently apply the same standards to surgery and the pharmaceutical industry, and anything “mainstream.’

Zilberberg reviews the relative roles of experimental evidence vs observational evidence. Her analysis is reasonable, but I think she overstates the utility of observational data a bit (and she admits to a fondness for this type of data). The bottom line is that each type of evidence (basic science, observational, and experimental — and even anecdotal) has its own strengths and weaknesses, and the best result comes from analyzing all kinds of scientific evidence and looking for a consensus of evidence. That is, in fact, OUR criticism of evidence-based medicine -over reliance on randomized controlled clinical trials and undervaluing other forms of scientific evidence. That is why we advocate for “science”-based medicine, and not just “evidence”-based medicine.

Each type of evidence, in fact, is abused. We criticize the inappropriate extrapolation from basic science to clinical claims, assuming causation from observational correlation, failure to realize the limits of clinical trials, and the use of pragmatic studies as if they were evidence for efficacy.

Zilberberg also clarifies her position by saying that she feels there is good scientific evidence for some of medicine, but it seems she differs from my position in how evidence-based modern medicine actually is.

We can argue endlessly about this question — how much of modern medicine is based upon solid evidence — each pointing to limited examples and essentially giving our bias. But there are some facts we can point to. Zilberberg writes:

While it is true that the oft-cited 5-20% number representing the proportion of medical treatments having solid evidence behind them is very likely outdated, the kind of evidence we are talking about is a different matter.

The “5-20% number” is not outdated — it’s a myth. Actually, I had previously heard 15% as the low end, but I guess that number keeps dropping. I wrote previously about this myth here. The 15% number was based upon an extremely small survey of primary care practices in the north of England — in 1961. That’s almost 50 years ago. The number was never very relevant, and now it’s a joke.

More recent surveys of medical practice come to very different numbers. Bob Imrie reviewed the published evidence:

Thus, published results show an average of 37.02% of interventions are supported by RCT (median = 38%). They show an average of 76% of interventions are supported by some form of compelling evidence (median = 78%).

Of course, where you draw the line for “supported by compelling evidence” will determine what the percentage figure is. But the bottom line is that the 15% figure is basically an urban legend, and “5%” is nothing short of propaganda. More reasonable estimates range much higher.

And — the point of EBM and SBM is that we can and should do better. We also need to do better in adhering to EBM guidelines where they exist, and in utilizing continuing medical education and other mechanisms of quality control to improve adherence to the evidence where it does exist.

The difference in spin is not subtle. We can look at the evidence and say: modern medicine has a culture of science, endeavors to be scientific, and basically the system works but the process is complex and messy and there are multiple ways in which we can do better. Meanwhile someone else can look at the same data and conclude: modern medicine is broken, it is based upon arrogance, authority, and greed, and we can just throw up our hands and conclude that any treatment is as likely to be of value as any other, no matter how silly it may seem scientifically.

My position is essentially the former. Zilberberg came off originally as being close to the latter (and judging by the comments, many readers took her position to be supportive of the latter), but now has clarified that she is somewhere in the middle.

CAM

Zilberberg also clarifies her position on CAM. She had previously written that she advocates a position of “equipoise” towards clinical claims. Even though she might not use certain modalities herself, she sees no basis to condemn the use of them by others. I characterized this position as political correctness gone wild — to the point of practical post-modernism. Now she writes:

My belief is that all modalities that may impact what happens to public’s health need to be evaluated for safety, not question. I think we both agree, since there is really no reason to think that something like homeopathy has anything that can help, by the same token we do not believe that it have anything that can hurt. Same with healing crystals, reiki and prayer. So, if a person wants to engage in these activities, and they are perfectly safe physically, be my guest. Other modalities, such as chiropractic, acupuncture, herbalism and the like, definitely need to be evaluated more stringently, as there is reason to think that they may cause harm.

This is a common position to take. Val Jones at SBM coined the term “shruggie” to refer to this position — in essence, if there is no direct harm, then who cares what people do. First, as I discussed very recently on SBM, there are many types of harm from unscientific medical modalities other than direct physical harm. So I do not find this position tenable for that reason alone.

Further, context is everything. There are actually a variety of positions that authors at SBM take when it comes to regulating medical practice. We all generally believe that medical professionals should not engage in nor promote unscientific methods. In fact, we should oppose their adoption and promotion, we should oppose their inclusion in universities and mainstream hospitals, and spending public funds on researching extremely implausible or already disproven modalities. That seems to be a point of difference between myself and Zilberberg.

I personally do not oppose individuals doing whatever they want when it comes to their own health. If you want to chew on tree bark (a vivid example given to me by someone else), go right ahead. What I object to is someone selling the tree bark and claiming that it cures cancer based upon nothing but legend and anecdote, and scaring their customers away from proven therapies in order to make the sale. I object to distortions of logic and science in order to confuse the public so as to better market worthless or harmful products. And I object to medical professionals looking the other way out of misguided political correctness, or simply a naivete as to the significant harm that is done.

SBM has a huge consumer protection mission, and it puzzles frustrates me that this mission is so often and so thoroughly misrepresented. This misrepresentation is deliberate — part of the “health freedom” movement — and seeks to portray all health care consumer protection activity as arrogant elitism and protectionism. This is identical to the intelligent design movement’s representation of all attempts at quality control in education as arrogant elitism.

What I don’t understand is Zilberberg’s apparent position that, while she knows homeopathy is utterly worthless, a physician should refrain from telling her patients exactly that.

Vaccine Skepticism

Zilberberg goes on to argue that she is not anti-vaccine, as she has been accused (not by me). I have no reason not to accept her word on this, and it is good that she has clarified her position.

But I do think she is displaying a lack of appreciation for the nature of the anti-vaccine movement. As an example, if one publicly expresses doubt about an aspect of currently accepted Darwinian evolution it would be nice if they understand the many ways in which the scientific discourse is exploited by creationists, so that they don’t accidentally give succor to an anti-scientific movement.

Likewise, any public discussion about vaccines, while it should be candid and completely honest, should ideally be done with an adequate familiarity with the anti-vaccine movement’s propaganda so that one’s words and positions are not easily exploited. In fact, while expressing skepticism about a particular vaccine or vaccine program, I would recommend specifically clarifying one’s position to distance themselves from the extremists. Otherwise you are inviting misinterpretation.

Conclusion

The take home message from this exchange is that, in my opinion, accusations of using harsh tone or of arrogance are an ad hominem distraction from the real issue — what is the optimal relationship between the practice of medicine and the underlying science of medicine.

Zilberberg engaged fully in this distraction, but is now slowly backing away (but not enough, in my opinion). I think this was largely due to the fact that she has been taken in by the very active and sophisticated propaganda campaigns of CAM proponents. She seems to have bought into their rhetoric, and did not read carefully enough into our writing at SBM to see through it.

We are approaching 1000 blog posts at SBM. I don’t expect critics to read every post, but a tiny bit of scholarly due diligence would be nice, before essentially buying into the lies and distortions of our critics.

We at SBM write frequently about the complexity and limitations of the science of medicine. That is our mantra — a nuanced and sophisticated approach to evidence is needed. But at the end of the day, some treatments are better than others. We can accept and reject practices based upon plausibility and evidence, even while there is a vast gray zone in the middle where we just don’t know yet.

It is misleading and ironic in the extreme to criticize promoters of SBM for taking a simplistic approach to evidence. That is the opposite of the truth. Meanwhile, promoters of all sorts of so-called CAM do take a simplistic and highly distorted approach to evidence, display an intolerance of uncertainty, systematically misrepresent the evidence to their clients and the public, think in stark black-and-white terms, engage in bait-and-switch deceptions, distort the positions of their critics, rely upon low grade evidence and logical fallacies for their claims, and then hide behind political correctness, post-modernism, distractions about “health care freedom”, special pleading (science can’t test my claims), and accusations of arrogance and paternalism.

All of this behavior is carefully documented in the pages of Science-Based Medicine. Would-be critics of SBM should try reading some of them before launching into misguided criticism of what is ultimately a straw man of our actual positions.

I take Zilberberg at her word that she is interested in genuine discussion, and she has at least moved in that direction. I recommend she step back, read some more of SBM and see what we actually have to say about science and medicine.

Posted in: Science and Medicine

Leave a Comment (16) ↓

16 thoughts on “Blog Discussion with an SBM Critic

  1. squirrelelite says:

    It will be interesting to see how this plays out. At least she has moved in the direction of seeking further discussion.

    One thing that struck me in reading her earlier posts was her preference for David Hume’s concept of an almost mathematical purity of proof which she states as:

    Vigorous debate is a characteristic of modern scientific philosophy, no less in epidemiology than in other areas. Perhaps the most important common thread that emerges from the debated philosophies stems from 18th-century empiricist David Hume’s observation that proof is impossible in empirical science.

    and then elaborates

    Some experimental scientists hold that epidemiologic relations are only suggestive, and believe that detailed laboratory study of mechanisms within single individuals can reveal cause–effect relations with certainty. This view overlooks the fact that all relations are suggestive in exactly the manner discussed by Hume: even the most careful and detailed mechanistic dissection of individual events cannot provide more than associations, albeit at a finer level. Laboratory studies often involve a degree of observer control that cannot be approached in epidemiology; it is only this control, not the level of observation, that can strengthen the inferences from laboratory studies. Furthermore, such control is no guarantee against error. All of the fruits of scientific work, in epidemiology or other disciplines, are at best only tentative formulations of a description of nature, even when the work itself is carried out without mistakes.

    While I think, and would guess that most working scientists also think, that there is always some residual uncertainty in any scientific conclusion and the possibility of some unobserved effect or process which scientists keep trying to ferret out; most scientists see science as a process of reducing that uncertainty. I think the quote from Stephen J Gould that you mentioned in Saturday’s SGU more accurately reflects the working concept of most scientists.

    In science, “fact” can only mean “confirmed to such a degree that it would be perverse to withhold provisional assent.” I suppose that apples might start to rise tomorrow, but the possibility does not merit equal time in physics classrooms.
    Stephen Jay Gould

    It would be interesting to see how her analysis would proceed if she based it on this more practical concept of “proof”.

  2. windriven says:

    “she wants “equipoise” with regard to all interventions, and would not dare dictate how research money is spent. ”

    Research money is a very scarce resource. Squandering this resource studying magic bracelets and homeopathic nostrums while multiple sclerosis cripples and cystic fibrosis suffocates isn’t balanced, it is criminal.

    This from nccam.nih.gov:
    “Appropriation: The FY 2008 appropriation for NCCAM is $121,577,000. NCCAM’s FY 2008 budget is flat, but remains at an historic high for funding of CAM research, research training, and information dissemination.”

    One hundred twenty million dollars. What might that investment accomplish if it were spent on research on breast cancer, spinal cord injury or lung cancer? Instead we get to find out that homeopathic remedies aren’t worth the water they are made from.

    Thanks Dr. Zilberberg, you’ve self-identified as a dipshit.

  3. WilliamLawrenceUtridge says:

    @windriven

    Not to mention the fact that that all that funding has not resulted in the NCCAM deciding to cease funding research on those modalities, and that much of it is spent on shoddy research that provides only ambiguous evidence and therefore CAN’T be used to equivocally say whether X “works” or not.

    The biggest issue I have with CAM is opportunity cost – that money could be spent on better medicine (or even a fancy car, I don’t care so long as it’s something actually useful), that time could be spent with friends and family (or eating ice cream and pizza, I don’t care so long as it’s not making you more miserable). If you’re going to give people hope, and make them devote scarce time and resources to that hope – don’t make it a false hope.

  4. David Gorski says:

    Dr. Zilberberg clearly has a bit of penchant for mind-body dualism, I’ve discovered. For instance, read this post:

    http://evimedgroup.blogspot.com/2010/08/allopathic-medicine-and-cam.html

    In it, she likens battles between SBM and CAM to those between science and religion, invoking Stephen J. Gould’s suggestion that science and religion are “non-overlapping magisteria” as a model for how we should deal with CAM and SBM.

    Because, I guess, that worked out so well for the creationism/evolution wars.

    She also uses a classic argument from ignorance:

    But what are we unable to measure? Oh so much! The burgeoning science of neurobiology, for example, has raised so many interesting questions about not only what the mind can do to the body, but what the body can do to the mind (please forgive this dualistic language). Why is this important? Because, due to our lack of adequate tools until recently, and because of the overwhelming complexity of the subject, we have traditionally neglected to include any measures of our patients’ and trial subjects’ neurobiological milieu into the consideration of differences between groups. But if randomization takes care of other systematic differences, should it not take care of the neurobiological ones? Perhaps, but without understanding the magnitude of variability of these characteristics in a population, one cannot begin to know how large a swathe of the population has to be enrolled in a study in order to smooth out these potential differences. And this goes for other so far unknown or unidentifiable characteristics. So what we think we learn from these trials is, much like in any other branch of science, subject to interpretation within the context of our knowledge today, and is, therefore, far from the universal and immutable truth. And the more we learn, the less absurd certain heretical ideas of the past seem. It’s OK, we are all in good company. Even Einstein was not infallible: when he said that “God does not play dice with the Universe”, he was alluding to his skepticism with regard to randomness of quantum motion, which has since been confirmed.

    In other words, because we don’t know everything about the brain and how it interfaces with the body, woo works–or, more properly, we can’t prove that woo doesn’t work.

  5. Jann Bellamy says:

    @ Zilberberg via Gorski:

    “And the more we learn, the less absurd certain heretical ideas of the past seem.”

    Nope, not true for CAM. A decade of NCCAM trials has not come up with a useful CAM therapy. Thus, the more we learn, the more absurd CAM seems.

  6. windriven says:

    Here are your tax dollars at work. I’ll save you the arithmetic. Your federal government and the dedicated public servants doing your bidding in the House and Senate saw fit to spend 1.17 BILLION dollars over the last 10 years studying needle fetishists, hand wavers, magical water, spinal crackers and other miraculous medical treatments.

    NCCAM Funding: Appropriations History

    Congress established the Office of Alternative Medicine in 1992 and the National Center for Complementary and Alternative Medicine in 1999. Funding appropriated for each fiscal year is listed below.
    National Center for Complementary and Alternative Medicine

    * FY 2010: $128.8 million
    * FY 2009: $125.5 million
    * FY 2008: $121.5 million
    * FY 2007: $121.6 million
    * FY 2006: $122.7 million
    * FY 2005: $123.1 million
    * FY 2004: $117.7 million
    * FY 2003: $114.1 million
    * FY 2002: $104.6 million
    * FY 2001: $89.2 million

  7. Wolfy says:

    And back in 1991-92, I believe the OAM received only 2 million. Those are some pretty impressive gains over the last 18 years.

  8. DevoutCatalyst says:

    “…the House and Senate saw fit to spend 1.17 BILLION dollars over the last 10 years studying needle fetishists, hand wavers, magical water, spinal crackers and other miraculous medical treatments…”

    But not a single lucky rabbit’s foot study. I’m miffed.

  9. JohnW says:

    “I think we both agree, since there is really no reason to think that something like homeopathy has anything that can help, by the same token we do not believe that it have anything that can hurt.”

    I like the assumption that homeopathy cannot hurt anyone. Unfortunately children have been harmed by a “homeopathic” treatment for teething pains. See the FDA alert: http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm230761.htm

    It actually looks like the company was taking advantage of the homeopathic label to sell something that reallly shouldn’t be considered homeopathic since it contains an actual active ingredient.

  10. Werdna says:

    Quotes like this drive me up the wall…especially the

    “Some experimental scientists hold that epidemiologic relations are only suggestive, and believe that detailed laboratory study of mechanisms within single individuals can reveal cause–effect relations with certainty. This view overlooks the fact that all relations are suggestive in exactly the manner discussed by Hume: even the most careful and detailed mechanistic dissection of individual events cannot provide more than associations, albeit at a finer level.”

    Ok but here “certainty” means something different than what a statistician would mean – and given that science relies heavily on math one would assume that would be the correct context to interpret it in. Certainty, to me anyway is far more about the ability to bound error than some difficult and needless goal of eliminating it. I’m not super familiar with Hume but even if he stated something to the effect of “error can not be eliminated” that’s entirely different than “error can not be bounded”

    “Furthermore, such control is no guarantee against error.”

    Again this seems to be a bit of mixing terminology. Is a probabilistic statement a guarantee? From a math POV I’d say yes – colloquially perhaps not.

    “All of the fruits of scientific work, in epidemiology or other disciplines, are at best only tentative formulations of a description of nature, even when the work itself is carried out without mistakes.”

    This goes back to what Dr. Novella wrote about the fallacy of perfection (what I would call a form of the fallacy of “arbitrary standard of evidence” btw) the fact that we lack an ability to eliminate error is irrelevant and believe it or not completely unnecessary. All that’s required to take the word of science over that of tradition (which IMHO is often what CAM is often argued on) is that science tends to give better answers.

  11. windriven says:

    @Wolfy

    Good memory. The money didn’t get serious (by government standards) until 1997 when it hit 12 million.

    @DevoutCatalyst
    I’m miffed too. Let’s write a grant request!

  12. MKandefer says:

    Werdna,

    I wrote the following in response to Marya.

    Marya said, “I would ordinarily say that yes, proven medicine would be great. However, I refer you to many other entries on this blog, as well as much peer-reviewed evidence to suggest that much of what we consider certain is far from it. So, if you can find “proven” medicine, then definitely, I will fall on the side of proven.”

    I suspect by “proof” you mean logical necessity. I suspect you mean this as you mentioned Hume’s criticism that science cannot have logical proof (the key word here is “logical”) and you used the word “certain”. This is not what most individuals mean when they say “proven”, and it isn’t the case among scientists. What most lay people and scientists mean by “proven” is given all the relevant information available it is probably the case that X (where X is some claim that follows from the information). This is of course not logical necessity, but to say that what we have proven in science isn’t logically necessary is a very weak claim. It’s logically possible that people could spontaneously regrow lost limbs. A set of propositions that are not contradictory is a logically possible set, and the number of examples we can construct are limitless.

    To illustrate how silly it is to expect logical necessity before accepting a claim. Suppose you were the prosecutor on a murder case and you had DNA evidence linking the alleged murderer to the victim, a murder weapon in their possession with only their fingerprints, and several independent witnesses and you were asked for proof that the suspect committed the murder? Do you think it is reasonable to say, “I have no proof as it is logically possible the alleged murderer didn’t commit the crime”? Isn’t it the more reasonable response to say, “Yes. We have proof. The presence of the murderer’s DNA at the crime scene means it is likely he was there. The fact that his fingerprints are the only ones on the murder weapon means it is likely that he used it for the murder. The fact that three people that do not know the victim or the murderer saw him do it, means it’s likely he committed the murder.”?

    Most people do not use “proof” in the logical sense and the way Hume was using the term, and I wasn’t either. Nor are scientists when they claim a certain treatment is proven effective for treating some condition.

    http://evimedgroup.blogspot.com/2010/10/addressing-comments.html

  13. Shannon says:

    Oh lord. I just realized she lives in the town I grew up in. It’s a lovely place but the woo is very strong there… despite the town’s very good university sciences program.

  14. DanaUllman says:

    As much as some people here may want to distance themselves from the term “ALLOPATHY” and “ALLOPATHIC MEDICINE,” these terms are a part of many leading medical institutions, accreditation agencies, government agencies, and all over the place.

    Drawing from a body of information developed by Dr. Bryan Hopping at wikipedia, deal with it…and accept it. The bottomline is that the term “allopathy” is a widely accepted modern term, except to a small group of medical fundamentalists and scientific denialists.

    http://en.wikipedia.org/wiki/Talk:Allopathic_medicine (look under Hopping’s huge list)…which includes links to exact references and more. Some of this list is below:

    – United States Dept of Labor – “There are two types of physicians: M.D.—Doctor of Medicine—and D.O.—Doctor of Osteopathic Medicine. M.D.s also are known as allopathic physicians.”
    – American Medical Association Journal of Ethics Research Funding Favors Allopathic Medications: “The enormous disparity between research funding for studies on conventional pharmacological therapies and nonconventional modalities reflects entrenched biases that promote Western allopathic medicine at the expense of promising treatments from non-Western systems of medicine.”
    – Journal of General Internal Medicine (Harvard Med School Faculty) “Comparison of osteopathic and allopathic medical schools’ support for primary care.” PMID 10632817
    – Journal of Vet Med Education “Part I: twenty-year literature overview of veterinary and allopathic medicine.” PMID 18339961
    John Gever. Med Page Today. Reviewed by Robert Jasmer, MD; Associate Clinical Professor of Medicine, University of California, San Francisco. “Nearly 13,000 graduates (84.6%) of allopathic medical schools in the U.S. landed one of their top three choices for a first-year residency slot, according to the National Resident Matching Program.”
    – Journal of the American Medical Association. PMID 18270355 “National survey of deans of all 125 accredited allopathic medical schools in the United States.”
    Journal of American Geriatrics. “Attitudes, experiences, and interest in geriatrics of first-year allopathic and osteopathic medical students.” PMID 18086123
    – National Residency Matching Program “The NRMP classifies SMS applicants into 6 applicant types: [Type 1] Graduates of U.S. allopathic medical schools. A graduate of a Liaison Committee on Medical Education (LCME) accredited U.S. allopathic school of medicine.”
    – Illinois State Legislature. Osteopathic and Allopathic Healthcare Discrimination Act.
    – Michigan State Legislature “A health care corporation certificate shall provide benefits in each group and nongroup certificate for the following equipment, supplies, and educational training for the treatment of diabetes, if determined to be medically necessary and prescribed by an allopathic or osteopathic physician:”
    – Florida State Legislature “The bill requires each Florida-licensed allopathic or osteopathic physician, in conjunction with the renewal of his or her license under procedures adopted by the DOH.”
    – American Medical Student Association. “AMSA RECOGNIZES the equality of osteopathic and allopathic medical degrees within the organization and the healthcare community as a whole.”

  15. weing says:

    You are mistaken. I, for one, do not want to distance myself from that term. And I don’t think anyone else does either. What we have noticed is that that term is frequently used by people such as you and it frequently serves as a red flag that bull crap is coming.

  16. DanaUllman says:

    Weing…Oh, don’t I wish you are right. Those “advocates” of homeopathy would now include the AMA, AMSA, the Dept of Labor, and so many more.

    Denialism is not dead, except to the denialists and the daft.

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