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Defending Science-Based Medicine

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.”

The Straw Man, False Dichotomy, Non Sequitur

The core of Dr. Egnor’s claim is a trifecta of logical fallacies. He writes:

I am not a supporter of “alternative medicine,” and I objected when an effort was made some years ago to expand alternative medicine here at Stony Brook. Alternative medicine, like traditional medicine, must be subjected to strict standards of evidence for safety and efficacy. Most types of alternative medicine fail to meet those standards, and therefore should not be endorsed by the medical profession.

Yet there is an irony in the efforts of “defenders of science” to protect the public from treatments and theories that are outside of the mainstream of medical practice. The greatest iatrogenic danger to patients isn’t chiropractors or homeopaths or vaccine “deniers.” It’s the doctors, nurses, and other medical personnel working in the traditional medical paradigm.

Dr. Egnor has clearly not read enough of our writings, or has not made an effort to fairly understand them, to accurately summarize them. He has earned a reputation as a sloppy thinker and poor scholar for this behavior. Note that he must agree with what we actually do – advocate for “strict standards of evidence for safety and efficacy.” But he wants to find some way to criticize his ideological foes, so the logical fallacies begin. First he constructs a straw man – that our goal is to protect the public from “treatments and theories that are outside of the mainstream of medical practice.” He develops this theme further when he writes:

I believe that much of the motivation for the “pro-science” priesthood isn’t patient safety or a genuine respect for scientific method but ideological hegemony. What bothers materialist ideologues like Novella and Orac is that there are people who challenge their materialist scientific worldview.

Any honest reading of Science-Based Medicine, NeuroLogica, or Respectful Insolence gives lie to this claim, which is no different than the accusations we have heard from homeopaths, energy healers, and charlatans of all stripes. We have clearly written that our purpose is to promote rigorous scientific methodology in medicine. We talk about method, and the targets of our criticism misinterpret this (deliberately or otherwise) as closed-minded “ideological hegemony.” But all we are really saying is that a specific claim does not meet the standards of science and evidence, and that we feel a single science-based standard of care should apply.

Dr. Egnor’s straw man is well known to us because we have heard it from proponents of unscientific medicine for years.  We might argue, for example, that a particular acupuncture study is unblinded and therefore cannot exclude the placebo effect as solely responsible for the outcome. We may also challenge that proponents of acupuncture have yet to propose of scientifically plausible mechanism for their claims. Defenders of acupuncture often counter with the non sequitur that we are biased against acupuncture because it is outside the mainstream and challenges our “materialism.” This does not address our criticisms, however. Such rejoinders are meant as a diversion – to draw attention away from the fact that a particular claim lacks evidence or plausibility.

Proponents of unscientific medicine also rely upon a false dichotomy – that between “mainstream” and “alternative” medicine. The purpose of the double standard is to deflect criticism while simultaneously carving out a double standard for claims that don’t meet the usual standard. We have also been very clear that our goal is to return to a single standard of care in medicine based upon good science.

What’s interesting is that Dr. Egnor can commit the same non sequitur right on the heels of admitting that what we actually do is legitimate. The cognitive dissonance must be deafening.

Tu Quoque

To defend his self-contradictory position Dr. Egnor must create a fiction that he can then criticize – that we aim our criticism outside of mainstream medicine but not within it.

The harm done by traditional practitioners of medicine is one of the leading causes of death in the United States. Where is the introspection by “skeptics” and “science defenders” like Drs. Novella and Orac about the enormous harm done to patients by themselves — traditional medical practitioners? What hypocrites.

This again is based upon a false dichotomy that we are trying to dispel, not promote. We apply the scientific standards we advocate to all of medicine, not just those “outside the mainstream.” It is a point we hammer home over and over, to the point where one must be willfully ignorant to miss it. “Where is the introspection” – one does not have to look far to find it, and so clearly Dr. Egnor did not do his homework (again, true to his reputation).

Just last week I wrote about the abuse of the term “syndrome” in medicine. I did not discriminate according to any false dichotomy about what is inside our outside accepted medicine. I discussed, for example, heavy leg syndrome and chronic fatigue syndrome, both diagnoses accepted within “mainstream” medicine. I have discussed the use of off-label medications, how to interpret the clinical literature, conflict of interest in the medical literature, and the debate about anti-depressant efficacy. David Gorski has written about transparency in clinical trials, barriers to practicing science-based surgery, and when the popularity of new surgical procedures outpaces the evidence. Mark Crislip has sharply criticized our own profession for the acceptance of pharmaceutical company lunches and other perks.

The claim by Dr. Egnor that we do not address issues of science or quality control within our own profession is not only a false dichotomy and a non sequitur, it is patently false.

But of course we do spend the majority of our attention dealing with the most anti-scientific challenges to modern medicine. It only stands to reason that proponents of science-based medicine would spend the majority of their energy attacking the most outrageous unscientific medicine that has managed to infiltrate health care.

Our focus also stems from the fact that this is a niche that we perceive is empty. We are pointing out that the emperor has no clothes because no one else is. The institutions of academia and medicine have been cowed by false notions of political correctness. The AMA was cowed by a successful restraint of trade lawsuit by chiropractors. The mainstream media are worse than useless – they are abetting the spread of pseudoscience. Promoting universal standards of science in medicine and directing our efforts at the worst abusers is our chosen mission. It is a mindless non sequitur (one that we are also familiar with from the proponents of unscientific medicine) to argue that we should be doing something else.

Risk vs Benefit

Which brings me to Dr. Egnor’s other claim – that “mainstream” medicine causes more harm than so-called “alternative” medicine. Dr. Egnor would have done well to first read Harriet’s excellent commentary on this claim. She points out the fallacy of focusing only on harm and not on benefit. Medicine (as any respectable clinician should know) is about risk vs benefit. Focusing on just risk gives a very distorted view of reality.

Of course medical mistakes harm more people than so-called alternative medicine – because mainstream medicine is orders of magnitude larger than alternative practice, and often deals with much more acutely ill patients.

Dr. Egnor focuses on hand washing and medical errors. Why, he wonders, are we not taking on these issues. As stated above, we do in that we advocate for science-based practices across the board. But also, reducing medical mistakes, while very important, is simply not our chosen focus. There are already institutions and systems in place that are working diligently on these problems. In fact, most physicians in academia will serve in some capacity in such efforts as part of their administrative duties. I sit on a credentialing committee that deals with these issues. Mark Crislip tells me he has spent most of his career directly involved in exactly these quality control issues.

So Dr. Egnor’s core claim is just another non sequitur and false premise. He might as well say we are hypocrites for not taking on insurance fraud. Don’t we care about tax payer money being lost due to physicians committing Medicare fraud? What about our colleagues who sexually abuse their patients? Of course we care – it’s simply not the mission of science-based medicine.

I also think that Dr. Egnor misses the boat on these quality control issues. He casually blames arrogance (because it is an easy accusation to throw around). I will admit that there may be a kernel of truth to the notion that personal physician arrogance contributes to poor compliance and medical mistakes. I have never argued that as a profession we are beyond reproach. In fact I often go out of my way to point out that there is much to criticize in mainstream medicine and there are individual physicians who lack compassion, ethics, competence, or all three. (None of which, of course, justifies any particular unscientific claim.)

But the solution to quality control issues is not to rail against arrogance, it is to focus on systems. Those who are actually engaged directly in quality control issues in medicine have learned that you cannot just preach to health care providers about hand washing and diligence. You do need to do this – but the best results occur when systems are put into place that make compliance easy and automatic. Simply placing hand washing gel dispensers outside every patient room did more to raise hand washing compliance than nagging ever could.

These issues are being effectively addressed within medicine.  One of the barriers to efforts to deal with these concerns have been unscientific thinking among our own colleagues. This is not an insurmountable barrier – but we do encounter poor logic and faulty reasoning everywhere. In fact I have argued that making a study of the worst examples of pseudoscience helps me recognize more subtle manifestations of sloppy thinking. Studying pseudoscience makes one a better scientist.

Be Nice

Dr. Egnor’s blog entry also includes this gem:

We are beset by an arrogant medical and scientific priestcraft, eager to call ordinary people “idiots” or “anti-science” or “deniers” because they hold viewpoints with which these particular scientists and physicians disagree.

This is similar to the “Attack on Mommies” gambit that RFK Jr. used to defend his anti-vaccine claims. Again, Dr. Egnor is simply not paying attention, or he doesn’t care. I have written specifically about how to talk to patients who have unscientific ideas. This is an issue about which we are very thoughtful, as it cuts to the heart of what we do.

We in fact have made a specific point not to attack patients or “ordinary people” for holding unscientific views. We have even likened this to “blaming the victim” – we see a scientifically illiterate public as a victim of poor education, a credulous media, and anti-scientific propaganda. We do, however, sharply criticize those who publicly defend or promote pseudoscience or attack science or scientific medicine. We try, in fact, to focus our criticism on their claims and methods and avoid ad hominem attacks.

If you enter the public debate on a topic by writing about it, speaking about it, and actively promoting a point of view – then you open yourself and your views up to criticism. You cannot then whine about being criticized by those who disagree with your point of view. That’s the whole point of public discourse.

Public criticism is also part of the culture of science. Science’s chief strength as a self-corrective system depends largely on open criticism. Scientific discourse, while it can be polite and professional, is also a take-no-prisoners meat grinder. Anyone who has ever attended a scientific conference has likely seen this first hand. Bad ideas are excoriated, as they should be.

Conclusion

This latest entry by Dr. Egnor, true to his form, is an incoherent hodge podge of logical fallacies and contradiction. It is also based on a gross and unfair misrepresentation of the proponents of science-based medicine, as can clearly be demonstrated by what we have actually written on this site over the past year.

It is further evidence that those who seek to undermine the integrity of science in order to promote their personal ideology will find common cause, despite even vast internal ideological differences. That is why Dr. Egnor can agree with our actual position with regard to unscientific medicine, but be so motivated to find something to criticize that he ends up making the same dubious arguments as the proponents of unscientific medicine he claims to oppose. This is why an attack on the defenders of science-based medicine can be found on a creationist website.

Posted in: Science and Medicine

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24 thoughts on “Defending Science-Based Medicine

  1. Pingback: NeuroLogica Blog
  2. David Gorski says:

    This may seem incongruous at first, but honestly I suspected that just such an attack was inevitable.

    So did I.

    After all, Dr. Egnor uses the same sorts of logical fallacies and techniques of twisting science to attack evolution and neuroscience as quacks and quack apologists use to attack scientific medicine. Moreover, in a previous post, Dr. Egnor pointed to his clinical experience and claimed that taking care of patients allows him to identify B.S. when he sees it:

    My own experience with medical research and education is that medical practice is a very effective check on b.s., because in medicine ideas often have immediately obvious consequences. Some of these consequences are deadly. Eugenics was the consequence of the application of the Darwinian understanding of human origins to medical practice, and is the most shameful aspect of medical practice in modern times. I love my profession, and I harbor considerable ill-will for eugenic ideology that brought so much shame and disrepute to my profession and so much harm to countless innocent patients victimized by “Darwinian medicine” 1.0.

    This is very similar to Dr. Jay Gordon’s reliance on his “own clinical experience” over science and well-designed clinical trials to conclude that vaccines cause autism.

    In any case, the most amusing thing about Dr. Egnor’s post is that the article he cites to attack medicine was published on Dr. Joseph Mercola’s website. As you know, Dr. Mercola is very quack-friendly, posting all manner of unscientific nonsense about medicine and boosting all manner of supplements. Besides Dr. Mercola, the article is also coauthored by Gary Null, who is an antivaccinationist, a promoter of cancer quackery, an HIV/AIDS denialist, and a maven of coffee enemas as well. Really, Dr. Egnor couldn’t have chosen a less credible couple of people to cite if he tried. (Well, maybe if he added in Mike Adams of NaturalNews.com.)

    I do like your point about one thing. Dr. Egnor so dislikes those who refute his nonsense about evolution that he’s willing to take the side of people whom he claims not to like (the quacks and antivaccinationists) as a rhetorical strategy to attack us.

  3. storkdok says:

    “My advice to Dr. Novella, Orac, and other arrogant medical clergy: go easy on the parents concerned about autism from vaccines, even though the evidence suggests that their fears are unfounded. They’re not idiots, and they shouldn’t be treated with scorn. A little humility on the part of doctors, and some respect for the right of people to hold other views (even if those views are wrong), and to act on those views, would be a good thing. Respectful discourse with patients who disagree with our advice, not scornful excoriation, is much needed.”

    I find it amazing that Dr. Egnor suggests that anti-vaccination views are harmless. He doesn’t see the clear and very real threat to public health. Measles is now endemic in the UK. This is the direct result of anti-vaccine proponents.

    I happen to be a parent of an autistic child, I hear the anti-vaccine quackery every day. This is not a simple disagreement, these people are making public health decisions based on pseudoscience that leads to a very real public health threat. If someone puts their views out there in the public and is trying to spread the pseudoscientific/anti-vax views, as a parent or someone with authority, I think they should have their views deconstructed to expose their logical fallacies.

    As a parent and a physician, I thank you and the other science based bloggers for your dedication to evidence based science/medicine that will actually help my son, and prevent harm to other children with autism.

  4. MarkH says:

    Yes, this is not surprising as David and Steven have noted. It’s part of crank magnetism and the general nature of cranks. The reason they make bad arguments is that they are incompetent at evaluating evidence. Thus it is not surprising that they fall for other types of nonsense, or that seeing others are attacking the mainstream priesthood, lend support to other crank theories that are challenging an imaginary orthodoxy.

    Egnor is just following the natural evolution of cranks.

  5. pmoran says:

    I object violently to the first sentence characterising scien-based medicine as a philosophy vying wiht other phiulosophies. Science exists to get us away from the armchair theroising that philosophy projects.

    Medicine is FIRST AND FOREMOST AND FIFTH a practicaL

  6. pmoran says:

    (Sorry, misfire again — Continuing with fewer spelling errors.)

    Medicine is first and foremost a practical discipline. It can define what it wants to achieve and design inquiries that can determine what methods might achieve those ends with the best balance of effectiveness, safety and affordability.

    Where does philosophy come in?

  7. pmoran says:

    The statement also slips into a trap set by those whose opinions we oppose.

    Every quack would like to portray science-based medicine as just one of many possible valid philosophies — and that they are thus engaged in legitimate scientific controversy.

    But Merry Christmas! (as we still say in Australia)

  8. The Blind Watchmaker says:

    Here, here.

  9. David Gorski says:

    Actually, Peter makes a good point. One of the favorite techniques of quacks is to invoke postmodernism and try to paint science and science-based medicine as just one of many equally valid narratives or world views–or philosophies, if you will.

    Now I’m off to see my family for Christmas Eve…

  10. mandydax says:

    I find it incomprehensible that a neurosurgeon could believe in mind/body dualism. In a Psych 101 class in college, we saw a documentary about Phineas Gage the railroad construction foreman who had that terrible accident that drove the iron rod through his brain. That made it very clear that the mind is an effect of the brain. I’m baffled.

  11. weing says:

    I think Egnor is a great teacher. Whenever I read his writing, I am reminded of our natural propensity for self-delusion. Whenever I am sure of something, I begin to wonder if I am self-deluded like him and start examining my assumptions. Thank you, Dr. Egnor.

  12. Peter – I did not imply that other philosophies of medicine are legitimate, nor that SBM is just a philosophy. The point is that we are advocating for what I wrote – “that medicine should be based upon the best science available, according to a single universal standard of rigorous methodology and valid logic and reason”

    There are others who want a different approach to medicine – they want no standard, or they do no want science to be the exclusive basis for medical practice, or they want their ideology to pass as science. These approaches are all deeply flawed.

    Like it or not, there are organized movements trying to change the scientific basis of medicine. I cannot criticize them without referring to them, and I disagree that I legitimize them merely by referring to them. I used the term “philosophies” loosely but accurately. If you have a better term I would be happy to substitute it in the future.

    Also – how can saying that someone advocates an anti-science philosophy imply that they are engaged in legitimate scientific controversy?

  13. pmoran says:

    Possibly “systems of medicine” would get us away from different perceptions as to what “philosophy” and “science” are. That is what the opponents of mainstream medicine (chiropractic, TCM, naturopathy, and other seat-of-the-pants guided practitioners) are trying to promote in its place, or alongside it.

    Our opponents want it to be seen that there are many va

  14. pmoran says:

    Caught again! Apologies. Trying again.

    I contend that there is no mainstream philosophy of medicine that would prevent it accepting the principles and philosophies of chiropractic, or TCM, or homeopathy, or “natural products are gentle and safe” — IF they produced an adequate observational (empirical) basis.

    For the mainstream is the only truly empirical and eclectic medical system. It can be so precisely because there IS no guiding philosophy in the usual sense of the word. So what, if more of its treatments are shown to “work” (better than placebo)? Isn’t that, more or less, what medicine is supposed to be for, and what proponents of the other systems also believe?.

    The competing systems (to the mainstream) all have guiding, universal principles describing the nature and causes of illness. These are arrived at through a priori or religious reasoning or quasi-religious personal revelation, rather than dispassionate observations (science). In contrast, the mainstream wanders hither and thither, touching upon this and that, wherever it is led by serendipity, technology, and going and looking, and testing ideas out . It uses an extraodinary variety of physical and psychological ploys, when compared to the one-size-fits-all tendencies of “alternative” remedies.

    The mainstream has other unique features. It is the only one that can explain how all the other systems of medicine came into being.

    It is the only one that is confident enough in its understanding of medicine to dare to challenge the others. It is amusing to note how the “alternative” systems can live and work together quite harmoniously, despite chalk and cheese understandings of illness that might place them more at odds with each other than with the mainstream. Yet they rarely ever challenge all these other world views that are “alternative” to theirs. They cannot without exposing their own tenuous holds upon reality.

  15. clgood says:

    Just to stir things up: Before it was called “science” it was called “natural philosophy”. I think a look at the dictionary will show that “philosophy” is often as misunderstood as “theory”.

    Great post, BTW.

  16. Nomad says:

    I have always found this to be Dr. Steven Novella’s most powerful tool in his skeptical toolkit. His ability to get to the core logical fallacies of an argument.

    I aspire to one day have the same level of mastery as Steve has.

  17. Jurjen S. says:

    As the father of a two year-old, I have very little patience for the “attacking the mommies” gambit. My wife initially had some worries concerning the vaccination schedule, worrying that it might indeed be “too many, too soon,” and as a result, she and I did some research, and concluded that there was no major cause for concern. That is to say, none that weren’t overshadowed by the concomitant risks in delaying or eschewing certain vaccinations, which we also researched. It’s fine to be skeptical, but skepticism does require that at some point, you accept (even provisionally) the available evidence.

    Also, I’m 38; I’ve had mumps, measles, and chicken pox (the latter twice), as well as some unidentified virus that came very close to killing me when I was 10 (I didn’t find out how close it was until a few years ago). I don’t see what’s so bad about my kid not going through any of those experiences if they can be avoided at minimal risk. And yes, I have nothing but contempt for a parent who thinks it would be better for his or her child to experience those diseases than to (horrors!) receive those nasty unnatural vaccinations. A massive part of human endeavor throughout history has been finding ways to stop nature from killing us, and we shouldn’t feel bad about it when we succeed to some extent.

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