The Wall Street Journal has an assessment of Probiotics in the Jan 13, 2009 issue entitled Bug Crazy: Assessing the Benefits of Probiotics (1). For some reason when I wander around the hospital on rounds people show me articles such as this and ask, so whatcha think about this?
Probiotics are interesting. They are live bacteria given to treat and prevent diseases. It is one of those overlap areas for scientific medicine and so called alternative medicine. There are good clinical trials to suggest areas where these agents are of benefit, but other aspects of their use are blown out of proportion for the real or imagined benefit probiotics may provide. Much of alternative medicine where it overlaps with real medicine is the art of making therapeutic mountains out of clinical molehills.
The Wall Street Journal article is the kind of reporting that drives. me. nuts. It drive me nuts because the reporting acts as if the underlying assumptions of the therapies are true.
I recently watched a special news report about John McCain leading the charge towards making legislative earmarks illegal. The Economist defines earmarks this way:
Earmarks, for the uninitiated, are spending projects that are directly requested by individual members of Congress and are not subject to competitive bidding.
Most Americans are rightly upset about the practice of slipping pet projects into larger, well-vetted, and consensus-built legislative initiatives. They know instinctively that it’s morally wrong to sneak in personal favors and appropriate tax payer dollars to special interest groups without allowing others to weigh in. I certainly hope that McCain and his peers will succeed in discontinuing this corrupt practice.
Coincidentally, just after I watched this news report about earmarks, I went online to catch up on my blog reading. The first post I encountered made reference to an opinion piece written by Deepak Chopra, Andrew Weil, Dean Ornish, and Rustum Roy in the Wall Street Journal. Chopra et al. were asking Americans to redouble their efforts to adopt healthy lifestyles (including wholesome diets and regular physical activity) as a means to promote good health and avoid disease. At the end of the article they slipped in a plea for President-elect Obama to consider integrating alternative medicine practices (which included everything from healthy diet to meditation and acupuncture) into a government-sponsored approach to health.
The quest of advocates of unscientific medicine, the so-called “complementary and alternative medicine” (CAM) movement is to convince policy makers, patients, and physicians that it does not deserve the rubric of “alternative,” that it is in fact mainstream. Indeed, that is the very reason why “alternative” medicine morphed into CAM in order to soften the “alternative” label. Increasingly, however, advocates of such highly implausible medical practices appear no longer to like CAM as term for their dubious practicies, because it still uses the word “alternative.” That is, of course, because they recognize that labeling something as “alternative” in relationship to scientific medicine automatically implies inferiority, and CAM advocates are nothing if not full of hubris. Such a term conflicts with their desire to “go mainstream,” and they most definitely do want to go mainstream, but they want to do it on their own terms, without all that pesky mucking about with science, evidence, and rigorous clinical trials. Consequently, they increasingly use a new term, a shiny term, a term free of that pesky “alternative” label. Now they want to “integrate” their unscientific placebo-based practice with real, scientific medicine. Thus was born the term “integrative” medicine (IM, an abbreviation that is the same as that for internal medicine, an identity that I don’t consider coincidence).
One of the biggest complaints we at SBM (or at least I at SBM) have about the attitude of practitioners of scientific medicine towards CAM/IM is that most of them do not see it as a major problem. Dr. Jones characterized this attitude as the “shruggie” attitude, and it’s a perfect term. Equally perfect is her analogy as to why “integrating” pseudoscience with medical science is not a good idea. I myself have lamented the infiltration of pseudoscience and outright quackery into medical academia and the role that the National Center for Complementary and Alternative Medicine (NCCAM) has played in promoting that infiltration. In addition, wealthy patrons of CAM/IM such as Donna Karan and the Bravewell Collaborative have been generous spreading their money around. In this increasingly cash-strapped health care environment, hospitals know on which side their bread is buttered and see the “integration” of woo into their service portfolio as a means of beefing up the bottom line with cash on the barrelhead transactions that require no mucking about with nasty insurance forms. In fact, services such as reiki, homeopathy, acupuncture, and others often require no forms other than credit card receipts for the patient to sign.
When we were forming the National Council against Health Fraud I wondered aloud to the president, Bill Jarvis, what we would do if society solved the chiropractic problem. Bill laughed and said there would never be an end to quackery claims.
How right he was. But why? Many express surprise that at this time of remarkable intellectual and scientific advance, so many people choose to believe in irrational medical claims. The answer I am used to is the one that explains the difference between the attraction of subjective versus the dryness of the objective; between reflex and conditioned responses and rational thought, and between immediate emotionally gratifying, low-level mid-brain reactions and slow-reacting, cool, higher level intellectual thought. These comparisons are all valid but in trying to answer the question, we can miss the constancy of human nature biology, the dimension of time flow, the changing nature of evidence, and as yet unemphasized, the changes and evolution of measurement.…
Before Evidence Based Medicine (EBM) was devised, and the randomized clinical trial (RCT) accepted as the so-called gold standard, our evidential decisions turned on balances or ratios of science/nonsense, rationality/irrationality, reality/delusion, and an estimate of plausibility/implausibility. We can see now that the concept of EBM introduced a new set of standards to our equations balances – proof by RCT and their derivatives, systematic reviews (SRs). The demand for proof by RCT and and SR relegated the previous standards, the unbalanced ratio concept, to the level of anecdote and “uncontrolled observation.” We had to start over again with a new standard.
This space has often hosted musings on the nature of scientific knowledge, on how medical science is based in methodological naturalism (MN), rather than supernaturalism. MN requires that our acquisition of knowledge about the natural world be based on natural phenomena. The reason for this should be quite obvious: the natural world is the only one that exists, for all intents and purposes, and explanations must be based on natural processes. Can you name any supernatural processes? Can you measure them? Of course not.
This bothers adherents of alternative medical practices. Since science doesn’t support their ideas, they would like to carve out exceptions to natural laws. Remember, we know quite a bit about the universe. We don’t understand exactly what matter is yet, but we can measure it and experience it without ambiguity. We know the universe has matter/energy; we understand pretty well the primary forces of electromagentism, gravity, small and weak nuclear; and there are probably a few other things whose effects we can measure even if they aren’t completely understood (dark energy, dark matter).
All of modern medicine works in ways consistent with our understanding of the universe. Even when we don’t completely understand something, it does not behave contrary to these laws. A beta blocker has never caused someone to levitate. No one has been revivified by electricity, a la Dr. Frankenstein (“That’s Frahnkensteen!“). Human bodies follow natural laws, and natural explanations are the ones that have explanatory power.
Since these natural laws explain what we see in the clinic and lab, what are the altmed gurus to do?
They have three main strategies, each of which is conveniently described by a logical fallacy. (more…)
On Science-Based Medicine, we strive to apply the light of science and reason on all manner of unscientific belief systems about medicine. For the most part, but by no means exclusively, we have concentrated on so-called “complementary and alternative medicine” (CAM) because there is an active movement to infiltrate faith-based, rather than science-based, modalities into “conventional” medicine. Indeed, such efforts are well-financed, both by public and private organizations, and are alarmingly successful at insinuating postmodernist and pseudoscientific beliefs into academia to form an unholy new monster that has been termed by some as “quackademic medicine.”
However, one pseudoscientific belief system about medicine that we at SBM have perhaps not dealt with as much as we should is the belief that, contrary to the overwhelming scientific consensus built up over 25 years, the Human Immunodeficiency Virus (HIV) does not cause Acquired Immune Deficiency Syndrome (AIDS). True, working with Tara Smith, our fearless leader Steve Novella has published an excellent primer on the phenomenon, but not on this blog. This belief system, which is commonly called HIV/AIDS denial or HIV/AIDS denialism, is championed by virologist Peter Duesberg, along with a panoply of groups, such as Alive & Well AIDS Alternatives and Rethinking AIDS; blogs, such as Science Guardian, HIV/AIDS Skepticism, and AIDS Is Over; podcasts, such as How Positive Are You?; books, such as What If Everything You Thought You Knew About AIDS Was Wrong? by Christine Maggiore; and movies, such as The Other Side of AIDS (which resembles in many ways the anti-evolution movie Expelled! and the pro-quackery movie The Beautiful Truth). The influence of HIV/AIDS denialism is horrific, too, particularly in Africa, where advocates of such nonsense, such as Matthias Rath, have advocated quackery over antiretroviral therapy and had the ear of South African President Thabo Mbeki, who lost power in late 2007.
On January 1, 2008 I wrote the first blog entry on Science-Based Medicine introducing the new blog. Now, by coincidence, I have the privilege of writing the last entry of 2008. It seems like a good time to look back over the last year and reflect on our little project.
I am happy to write that by all measures SBM has been a satisfying success. Most blogs end after a few months. We not only kept up our schedule for the entire year, we expanding our writing about midway through the year. Given that there are millions of blogs, by necessity most blogs are relatively obscure. SBM rather quickly garnered a respectable readership and gained the attention of the some in the media as well as those with oppossing views.
I am very proud of the quality of the articles we have published here. Of course I have to thank all of my co-bloggers – David Gorski, Kim Atwood, Harriet Hall, Wally Sampson, and Mark Crislip who were with me from the beginning and Val Jones, David Kroll, Peter Lipson, and David Ramey who joined us part way through the year. Every week they each contributed a magazine-quality article, and then hung around to discuss their articles and others in the comments section. They all do this without any compensation, out of a pure desire to have a positive effect on the world.
A few years ago, at a skeptics conference in Los Angeles, Stephen Barrett of Quackwatch had just finished giving a talk and was fielding questions from the audience. Someone asked, “why don’t you ever talk about how dangerous regular medicine is?” Dr. Barrett, with a look of bewilderment in his face and a tone of exasperation in his voice, replied: “This is what I do.” That was his way of responding to a question that had nothing to do with his talk, as should have been obvious to both the questioner and the rest of the audience. The question might as well have been “why don’t you ever talk about global warming”?
If people are going to enter the fray of debate, at least they ought to play by the rules. One who doesn’t is the Intelligent Design apologist Michael Egnor, a nice counter-example to the popular myth that neurosurgeons are necessarily intelligent. I’m aware that Steve Novella posted the day before yesterday in response to Egnor’s recent lament about our close friend Orac and about Dr. Novella himself. I couldn’t help but stick in my two cents, however, because deconstructing Egnor’s essay is like shooting fish in a barrel, and it seemed appropriate for Boxing Day. I have avoided reading Dr. Novella’s piece so as not to color my own thinking, so please forgive any redundancies (speaking of that, I’m not the first to make the obvious pun of Egnor’s name). My post will be short and sweet and sour.
Science-based medicine is more than a website. It is a philosophy of medicine that is actively vying with other philosophies for dominance in the world of medicine. We believe that medicine should be based upon the best science available, according to a single universal standard of rigorous methodology and valid logic and reason. Others desire a double-standard, so that they can be free to practice or market whatever they wish without having to meet strict scientific standards. Still others have a non-scientific ideological world-view and want public policy to accord to, or at least admit, their personal beliefs.
I therefore expect that we will be attacked by proponents of unscientific medicine in all its forms. Yesterday, however, we were attacked on the Evolution News & Views website of the Discovery Institute by creationist neurosurgeon, Michael Egnor. This may seem incongruous at first, but honestly I suspected that just such an attack was inevitable.
Many science bloggers, David Gorski and me prominent among them, have taken on both the DI and Dr. Egnor specifically over many anti-scientific arguments he has put forward over the last couple of years. We have sparred mostly about evolution in medicine, neuroscience and consciousness, and the materialist underpinnings of modern science. Dr Egnor’s day job, however, is that of a (from what I can tell) respected neurosurgeon, so I always wondered what he thought of his sparring partners’ writings about science-based medicine.
His entry yesterday ends any speculation – he wrote an incoherent, logical fallacy-ridden screed that would make any snake-oil peddler proud. This reinforces a point I have made in other contexts – all anti-scientific philosophies have science as a common enemy, and will tend to band together in an “unholy alliance” against those advocating for scientific rigor or defending science from ideological attack. That is why a website that is ostensibly about the “misreporting of the evolution issue” would post a blog attacking science-based medicine as an “arrogant medical priesthood.”