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Dummy Medicine, Dummy Doctors, and a Dummy Degree, Part 2.0: Harvard Medical School and the Curious Case of Ted Kaptchuk, OMD

Review

The recent albuterol vs. placebo trial reported in the New England Journal of Medicine (NEJM) found that experimental subjects with asthma experienced substantial, measured improvements in lung function after inhaling albuterol, but not after inhaling placebo, undergoing sham acupuncture, or “no treatment.” It also found that the same subjects reported having felt substantially improved after either albuterol or each of the two sham treatments, but not after “no treatment.” Anthropologist Daniel Moerman, in an accompanying editorial, wrote, “the authors conclude that the patient reports were ‘unreliable,’ since they reported improvement when there was none”—precisely as any rational clinician or biomedical scientist would have concluded.

In Part 1 of this blog we saw that Moerman took issue with that conclusion. He argued, with just a bit of hedging, that the subjects’ perceptions of improvement were more important than objective measures of their lung function. I wondered how the NEJM editors had chosen someone whose bibliography predicted such an anti-medical opinion. I doubted that Editor-in-Chief Jeffrey Drazen, an expert in the pathophysiology of asthma, had ever heard of Moerman. I suggested, in a way that probably appeared facetious, that Ted Kaptchuk, the senior author of the asthma report, might have recommended him.

Editorial Cronyism?

I wasn’t being facetious, even if I was a bit snide. In a 2009 article Kaptchuk touted Moerman’s notion of “the meaning response,” also discussed in Part 1. In a 1998 article, one of Kaptchuk’s early forays into the placebo topic, he had thanked Moerman and others “for advice, discussion, and feedback.” In the Acknowledgments for his 2002 book Meaning, Medicine, and the “Placebo Effect,” Moerman returned the complement to Kaptchuk. In a very recent essay on “placebo studies and ritual theory,” Kaptchuk showed some serious cultural anthropology chops with a serviceable impression of Moerman:

…healing rituals are never simply enactments of plots, stories or assertions of truth. Instead, they are compelling multi-sensory dramas involving evocation, enactment, embodiment and evaluation. Rituals and their sensory, affective, moral and aesthetic components transmute the mythos into an experiential reality for participants. Metaphors and symbols, the healer’s prestige, social interactions with relatives and community members in the course of preparation and performance of the ritual, and gesture, recitation, costume, iconography, touch, ingestion and the physical ordeal—all provide vehicles for and multi-dimensional guideposts to a process that is meant to transform a patient from brokenness to intactness.

Authorship by Committee and Mixed Messages

The asthma trial authors themselves seemed ambivalent about the meaning of their results. Here is the larger passage from which Moerman culled the “unreliable” comment:

…although improvement in objective measures of lung function would be expected to correlate with subjective measures, our study suggests that in clinical trials, reliance solely on subjective outcomes may be inherently unreliable, since they may be significantly influenced by placebo effects. However, even though objective physiological measures (e.g., FEV1) are important, other outcomes such as emergency room visits and quality-of-life metrics may be more clinically relevant to patients and physicians.

David Gorski has previously mentioned that his “jaw dropped” when he read those words; so did mine, and so, everywhere, should jaws of asthmatic patients and competent physicians drop. The two sentences are contradictory: if the first is true, the second—essentially similar to the theme in Moerman’s editorial, weasel words and all—is perverse. How could the same authors have written both? Perusing the list of authors provides some hints:

Michael E. Wechsler, M.D., John M. Kelley, Ph.D., Ingrid O.E. Boyd, M.P.H., Stefanie Dutile, B.S., Gautham Marigowda, M.B., Irving Kirsch, Ph.D., Elliot Israel, M.D., and Ted J. Kaptchuk

Thus there were eight authors, suggesting that there may not have been a unanimity of opinion. Of the eight, five—M.E.W., I.O.E.B., S.D., G.M., and E.I.—are identified as “from the Division of Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital and Harvard Medical School” (the same Division, as I mentioned in Part 1, that spawned NEJM Editor Jeffrey Drazen). It’s a safe bet that those five subscribed to the first sentence quoted above, but not to the second.

I don’t know about the other two authors, but Ted Kaptchuk would appear to agree with the second sentence. Here he’s quoted in the Brigham and Women’s Hospital press release:

“We chose to study patients with asthma because earlier evidence had suggested that placebos would change the underlying medical problem,” explains senior author Ted Kaptchuk, Director of the Program in Placebo Studies at BIDMC and Associate Professor of Medicine at HMS. “While I was initially surprised that there was no placebo effect in this experiment [after looking at the objective air flow measures] once I saw patients’ subjective descriptions of how they felt following both the active treatment and the placebo treatments, it was apparent that the placebos were as effective as the active drug in helping people feel better.”

…adds Kaptchuk, the study results imply that placebo treatment is just as effective as active medication in improving patient-centered outcomes.”It’s clear that for the patient, the ritual of treatment can be very powerful,” notes Kaptchuk. “This study suggests that in addition to active therapies for fixing diseases, the idea of receiving care is a critical component of what patients value in health care. In a climate of patient dissatisfaction, this may be an important lesson.”

Let’s see: “patient-centered outcomes” are now defined as feeling better but not being better? (I wonder if Don Berwick, the nation’s most influential exponent of patient-centered care, would agree). According to whom? Other press reports were even worse:

Treatment, not medicine, helps asthma patients feel better

NEW YORK, July 15 (Reuters Life!) – Inhaling albuterol helps asthmatic lungs work better, but patients who get it don’t feel much better than those treated with a placebo inhaler or phony acupuncture, according to a U.S. study.

The results, which appeared in the New England Journal of Medicine, demonstrate the importance of, literally, caring for patients and not just providing drugs, said co-author Ted Kaptchuk of Harvard Medical School.

The findings also demonstrate the impact of the so-called “placebo effect,” or the phenomenon seen in clinical trials when people given inactive, fake “treatments,” such as a sugar pill or saline, show improvements.

“My honest opinion is that a lot of medicine is the doctor-patient relationship,” Kaptchuk told Reuters Health.

“A lot of doctors don’t know that, they think it’s their drugs. Our study demonstrates that the interaction between the two is actually a very strong component of healthcare.”

Treatment of Asthma now Possible with Placebo Treatments

A New study says, “Placebo treatments are equally effective in the treatment of asthma like [sic] any asthma medications.”

According to the researchers, the main reason behind proposition of this study is that several asthma patients have reported that they felt improvement in their asthma symptoms after they received placebo treatments. These treatments also include inhaler treatments and fake acupuncture. The improvement is similar to what they feel after taking asthma medication such as albuterol.

But the researchers also mentioned that unlike asthma medications, the placebo treatments are not capable of affecting the functioning of the lung.

The researcher of the study, Mr. Ted Kaptchuk said, “The practice of treatment can be highly effective for the patients”. “The study also recommends that patients should value not only the treatments for improving diseases but also the intensive care they receive from their healthcare providers” he added.

Mr. Ted Kaptchuk also said, “In the initial stage of the experiment, placebo treatments fail to make any impact. But later, when I observed that patient’s subjective descriptions about what they felt after receiving the two treatments then I concluded that placebo treatments work as well as other asthma treatments”.

At least one blog, citing the Reuters report quoted above, reported that “placebos were just as effective as real therapy” without even mentioning the trial’s having found a discrepancy between objective findings and subjective reports.

I am aware that authors of journal articles can’t be expected to control how every reporter characterizes those articles, but it’s fair to say that the emphasis of the various quotations attributed to Kaptchuk—which, as far as can be gleaned from the web, are accurate—was essentially the opposite of the study’s most important finding.

From Campus Radical to AltMed Superstar

You might have noticed that Kaptchuk’s is the only name on the list of authors that is not accompanied by the mark of an advanced degree, as I will eventually discuss. Like Moerman, Kaptchuk lacks formal training in either modern medicine or biomedical science, although he has learned a lot about the history and methods of clinical trials. How did he get to be Senior Author of an article published in the New England Journal of Medicine, and how did he become Associate Professor at the Harvard Medical School?

Here is the short version:

I was interested in science for a long time. In college, I studied religion and philosophy. Then I studied Chinese medicine in China and I came back and was a practitioner of Chinese medicine. When people became interested in alternative medicines, they asked me to help out at Harvard Medical School. I realized that in order to survive there, one had to become a scientist. So I became a scientist.

Here is the beginning of the longer version. Kaptchuk graduated from Columbia University in 1968, having majored in Asian philosophy. While there he was Chairman of the radical group Students for a Democratic Society (SDS), just prior to the emergence of its more famous chairman, Mark Rudd. I mention this not to commie-bash, but because it helps to elucidate some of Kaptchuk’s later opinions (hint: he has no trouble agreeing with both sentences in the jaw-dropping paragraph quoted above) and to demonstrate some of the ironies of his later choices.

After graduation, in Kaptchuk’s own words, ”I worked in the welfare and social services trying to help people.” During this time “I decided that I wanted to learn a healing art but was disillusioned with some of the aspects of Western allopathy and decided to learn acupuncture.” Kaptchuk pursued training with Asian practitioners in California and “studied every book in English on the subject,” but by 1972 had decided that this would not be sufficient:

Because of the relative unknowness [sic] among non-Chinese Americans of acupuncture and Dr. Hong’s limited practice, I cannot get enough experience to adequately master this healing art. In addition, there is a greater reluctance among other Chinese doctors who have more patients to have a student observe because of legal restrictions concerning their practice in the United States.

Kaptchuk reports having next spent a year in Taiwan, followed by 2.5 years in Macau (click on the image to enlarge):

Within a few years of his return to the United States, Ted Kaptchuk published the book that made him an alt-med superstar:

It is this book that I will discuss in the next part of this series.

The Dummy Series:

  1. Dummy Medicines, Dummy Doctors, and a Dummy Degree, Part 1: a Curious Editorial Choice for the New England Journal of Medicine
  2. Dummy Medicine, Dummy Doctors, and a Dummy Degree, Part 2.0: Harvard Medical School and the Curious Case of Ted Kaptchuk, OMD
  3. Dummy Medicine, Dummy Doctors, and a Dummy Degree, Part 2.1: Harvard Medical School and the Curious Case of Ted Kaptchuk, OMD (cont.)
  4. Dummy Medicine, Dummy Doctors, and a Dummy Degree, Part 2.2: Harvard Medical School and the Curious Case of Ted Kaptchuk, OMD (cont. again)
  5. Dummy Medicine, Dummy Doctors, and a Dummy Degree, Part 2.3: Harvard Medical School and the Curious Case of Ted Kaptchuk, OMD (concluded)

 …

The Harvard Medical School series:

  1. Dummy Medicine, Dummy Doctors, and a Dummy Degree, Part 2.3: Harvard Medical School and the Curious Case of Ted Kaptchuk, OMD (concluded)

Posted in: Acupuncture, Chiropractic, Clinical Trials, Health Fraud, Herbs & Supplements, History, Medical Academia, Medical Ethics, Naturopathy, Pharmaceuticals, Science and Medicine, Science and the Media

Leave a Comment (83) ↓

83 thoughts on “Dummy Medicine, Dummy Doctors, and a Dummy Degree, Part 2.0: Harvard Medical School and the Curious Case of Ted Kaptchuk, OMD

  1. windriven says:

    So much of this leaves me slack-jawed, but this hit me like a hammer:

    “…adds Kaptchuk, the study results imply that placebo treatment is just as effective as active medication in improving patient-centered outcomes.”

    Even if this bit of specious nonsense were true, why would any sentient being opt for a treatment that left them subjectively better and objectively not when treatments are available that leave them subjectively and objectively better?

    This is one of the characteristics of quackery consumers that I will never understand: why one earth would you choose nonsense when proven, powerfully effective medical treatments are available? Maybe if you had some essentially untreatable horrific anaplastic carcinoma, but asthma???

    As an aside, I heard a radio advertisment for, I think, Cancer Centers of America that contained two words that made my blood run cold: naturopathic oncologist.

    Good grief.

  2. stewiegriffin81 says:

    The thing that really annoys is that Kaptchuk’s and Moerman’s conception of what constitutes patient centered outcomes is falsely narrow. Most (all?) patients would not like their life shortened. Most (all?) patients would not like to go to the hospital unnecessarily . Both of these outcomes (mortality and hospitalisation) we know are reduced with the application of science based asthmatic medications (and the pre-test probability that placebo reduces this is essentially zero), and it’s extremely plausible that these are important patient centered outcomes. Why was there no honest discussion of these patient centered outcomes by Kaptchuk or Moerman? How on earth could the authors imply that emergency room visits are clearly entirely subjective when there is no good evidence for this? It’s outrageous.

  3. Earthman says:

    It seems Mr Kaptchuk has either not read or not understood the paper to which he has contributed.

    I am also intrigued by his description of how he became a ‘scientist’.

    “I realized that in order to survive there, one had to become a scientist. So I became a scientist.”

    How did he do that? Put on a white coat? He is clearly not thinking like a scientist.

  4. Todd W. says:

    Wow. Kaptchuk’s statements lend even more weight to a concern I raised in discussing the asthma study as an example of deception in research and some of the ethical concerns around the issue.

  5. daijiyobu says:

    “The Web” book was required reading in ND / not-a-dr.’ school.

    I look back now on the title and think:

    the perspective that has no rigor;

    the woo that has no woomeister…

    Anyway, brings me back to my point that using such sources as a foundation for diagnosis and treatment does not lead to one being a

    physician.

    Metaphysician…yes.

    -r.c.

  6. windriven

    “why would any sentient being opt for a treatment that left them subjectively better and objectively not when treatments are available that leave them subjectively and objectively better”

    Well, for some people asthma medication does have a downside. It’s been a humid summer and I’ve had some of my typical mild asthma symptoms and I have to kinda force myself to use the inhaler. After use, I get this jittery sensation, (like having a cup of coffee and a few donuts for breakfast), my hands shake a bit, which is a nuisance in my line of work and my chest fells kinda tingly. This is temporary discomfort, usually wears off in about a half hour. But, when my symptoms are mild, it’s just enough to make me want to procrastinate/forget, even though I know in the long run it’s better for me to use the inhaler. So I can relate to the temptation to use something (a placebo) that won’t have the side effects, but will make me “feel” better*.

    This does bring up a question in my mind, though. What about nocebo responses? Patients who have been treated for asthma have an expectation that the treatment will have side effects, do some of them report side effects with the placebos?

    *If patients are actually feeling better, not just reporting that they feel better to please doctors.

  7. WilliamLawrenceUtridge says:

    He should write a book: Placebo medicine or, how to feel better until you die.

  8. windriven says:

    @michele

    “So I can relate to the temptation to use something (a placebo) that won’t have the side effects, but will make me “feel” better*. ”

    But you don’t, do you? It is a matter of thinking things through and you are a thoughtful individual.

    I can relate to the temptation to smoke a fine Macanudo this evening. It would certainly make me feel better subjectively. Objectively, not so much.

  9. Purenoiz says:

    I think there is a large segment of patients who find the side effects from pharmacologic agents to be so deleterious to the quality of life, that getting off the medications is a strong motivating force. Many people are not educated to know the difference between Subjective and Objective outcomes. sCAMmers focus on the prior since they can rarely effect the latter; n-3′s EFA’s at an appropriate dose i.e 3 grams daily can effect TG levels, probably the exception to the rule.

  10. Kaptchuk et al need to be very careful when drawing the conclusion that the subjects actually felt better.

    While that is possible, what they actually have is a subjective conclusion that the patients felt better.

    There is the distinct possibility that this is not an objective reporting by the researchers of a subjective assessment by the patients, but instead the researchers themselves are also making their own subjective assessment of the patients condition.

  11. Scott says:

    I think the reasoning process being followed (inasmuch as there is one) looks something like the following:

    ” is effective and superior to conventional medicine.”
    ” only produces subjective responses, while conventional medicine produces objective responses.”
    Therefore
    “Subjective responses are effective and superior to objective responses.”

    It’s the only conclusion that doesn’t require them to admit that their first premise is false.

  12. # windrivenon 19 Aug 2011 at 10:38 am

    windriven -

    “So I can relate to the temptation to use something (a placebo) that won’t have the side effects, but will make me “feel” better*. ”

    But you don’t, do you? It is a matter of thinking things through and you are a thoughtful individual.”

    Well shucks! Thanks, but one might easily say I am a worried individual, who weighs unseen dangers too heavily*. Regardless, we humans are prone to developing rationalizations so that we might avoid momentary discomfort even if it is at the cost of long term health benefits.

    Kaptchuk’s analysis seems to open the door on a good set of rationalizations.

    I only meant explain that there is a temptation to avoid real treatment, due to temporary side effects. There wouldn’t be much temptation to use a placebo (and not get the object health results) if there were no side effects.

    This is only to suggest why a person with asthma might be interested in a subjective treatment that doesn’t give objective results, not to say that they are correct in pursuing that course.

    *In fact, I’m pretty sure people have said that. :)

  13. David Gorski says:

    As an aside, I heard a radio advertisment for, I think, Cancer Centers of America that contained two words that made my blood run cold: naturopathic oncologist.

    As well they should:

    http://www.sciencebasedmedicine.org/index.php/cancer-treatment-centers-of-america-and-naturopathic-oncology/

  14. Tell it like it is says:

    The web has a weaver – of truth, lies, and deceit.

    Jenit Devis was the key witness in ‘The Pendle witch trial’ – a trial that took place in the northern British city of Lancaster in 1612.

    Jenit Devis was nine years of age when she gave her ‘evidence’ – puerile evidence that would lead to the execution of 10 people – including all members of her own family.

    Twelve years later, eleven people were hanged for witchcraft, based upon ‘evidence’ presented by an eleven-year-old boy.

    Nine days after the hangings, the King heard of the incident and being sceptical of such trials, he ordered the boy to be ‘cross-questioned’ by a member of his privy council.

    Under cross-question, the boy confessed that he was telling lies – and that he was actually part of a conspiracy to extort livestock from local farmers – and if they failed to ‘pay their dues’ the wives would be ‘shopped’ as witches – which the perpetrators did – even though doing so meant that they cut off their livelihood (so much for critical thinking).

    Three thousand miles away from Lancaster, in 1692, ‘Witch trials’ took place at Salem in Massachusetts. These trials are probably the most infamous in history.

    Dalton’s ‘Country Justice’ was a publication to aid Magistrates with interpreting the law. At the Salem witch trials, the Magistrate referred to his copy of ‘Country Justice’, which suggested that children were suitable witnesses in trials – citing how Jenit Devis was the ‘key witness’ for penetrating a ‘witch’s coven’ at ‘The Pendle witch trial’.

    Most of the ‘evidence’ at Salem was given by children. Nineteen people were executed on the word of these children.

    During Hitler’s regime in the nineteen thirties and forties many children gave evidence that resulted in the killing of their ENTIRE lineage – not one member of their family or their relations were spared. Machiavelli also did this to people who dared to cross him.

    Today some might find such practices disturbing – at the time they must have been terrifying! These were practices born out of irrational fear that turned neighbour against neighbour – and relative against relative.

    Since the time of Jenit Davis, through scientific comprehension and rigour we have become less credulous of witchcraft and ‘magic potions’, and more rigorous in our search for empirical evidence that replaces blind trust with scientific certainty.

    However, even in our modern technological age, we still struggle to control fear – particularly during times of crisis – a time when truth can be the hardest thing of all to define.

    Watch the DVD ‘Life is beautiful’ and see how riddles take on a much bigger significance.

    On ‘understanding Chinese medicine’, watch the DVD ‘The painted veil’ – and ask yourself “Are children being brainwashed?”

    With regards to the publication ‘The web that has no weaver’ – Philius Barnum once said something along the lines of “There is no such thing as bad publicity – all publicity is publicity”. Without wishing to stick needles in the haystack, or anywhere else, in my opinion, by the reviewing the said book, the reviewer is both providing publicity and giving the impression that they endorse the content.

    Have a good weekend.

  15. windriven says:

    I don’t want to run us into the weeds on this post but I just read Dr. Gorski’s June 2010 blog on naturopathic oncology . In it he quoted from the (I couldn’t make this stuff up) “Oncology Association of Naturopathic Physicians (OncANP)” that among their, ahem, treatments is something called orthomolecular medicine. I understand the meaning of the prefix ortho and the meanings of both of the words but string them all together and maybe not so much. So I googled it.

    Orthomolecular medicine is naturopathological speak for megavitamin therapy.

    Do I hear PT Barnum laughing hysterically in the distance?

  16. DevoutCatalyst says:

    Haha, windriven, I got suckered into trying orthomolecular medicine in the early 80s by a mavricky MD looking for attention or something. Anyways, his medicine didn’t work, but at one point, after a few days on a prescribed water fast, I telephoned him at 3AM with the news that I couldn’t take it any longer, that 3AM rude awakening is the only good thing that came out of that particular therapeutic relationship, and the positive effects of that lil’ gotcha developed many years later — I can laugh at that moron today. PT Barnum isn’t just laughing, he’s spinning like a lathe.

  17. TILIS – I’m saddened that you endorse the British and American witch trials, Nazi Germany’s genocide and Machiavelli oppressive practices.

    I hope you will reconsider your position and stop giving those practices free advertising.

  18. windriven says:

    @michele

    Did TILIS endorse those? I didn’t read it that way.

  19. windriven says:

    @DevoutCatalyst

    I’d ask which medical school this nut job attended but the way things are going it could have been almost any of them. Good for you for seeing the light and moving on.

  20. pmoran says:

    I have a soft spot for Ted. He is being taken apart here for newspaper quotes that suggest the possession of an exaggerated perception of the impact of psychogenic influences upon human illlness. But lots of people have that without necessarily encouraging more serious forms of quackery or opposing mainstream medicine where it is is obviously effective.

    Listen to what Kaptchuk says about Western science in “The Web That Has No Weaver”.–

    Western science can be criticised for insensitivity, for arrogance, for storming Heaven but the fact remains that it is humble, and humility is integral to the best scientific thought. For all its misuses, the idea of progress implies that not everything has been achieved, that more is yet to come. In order to remain science, science must believe thatwhat it discovers tomorrow may undermine and revolutionise everything it believes today. Western science, unlike traditional Chinese thought, is necessarily receptive to the new.

    Give him credit for that.

    Also consider it remarkable that someone coming from the background that Kimball has just described has produced studies that have in effect completely destroyed the mystical foundations of acupuncture.

    This man may not be a “proper doctor” but he looks to be a true scientist. He is prepared to test his own hypotheses — to the extent that in the above he admits to being surprised that there were no objective responses to placebo in asthma. That is such a placebo-responsive conditions that 80% of the reported subjective improvement with the use a bronchodilator was achievable with placebo.

    This may have something to do with why he is now at Harvard.

  21. Zetetic says:

    Tell it like it is…

    I read your post and forgot what this post was all about!

  22. @Windriven, shhh, I was trying to be cryptic… If I explain it’s not as much fun.

    But,

    TILIS said “With regards to the publication ‘The web that has no weaver’ – Philius Barnum once said something along the lines of “There is no such thing as bad publicity – all publicity is publicity”. Without wishing to stick needles in the haystack, or anywhere else, in my opinion, by the reviewing the said book, the reviewer is both providing publicity and giving the impression that they endorse the content.”

    So if Kimball Atwood’s mention of the above book can be construed as an advertisement, endorsement then TILIS’ mention of witch trails, nazism, etc should be considered an advertisement, endorsement.

    I was pinging on TILIS a bit in the hopes of getting them to reconsider their critique. This is probably a poor habit on my part.

  23. woo-fu says:

    @Micheleinmichigan

    I have the same issue with my asthma meds. I don’t like the side effects either, but I do like breathing! ;)

    *If patients are actually feeling better, not just reporting that they feel better to please doctors.

    That’s an important point. Certainly any testimonials or surveys have that as an inherent bias. How is that bias minimized?

    @WLU I’d love to see the cover illustration for such an edition, something Addams or Gorey, perhaps?

  24. JPZ says:

    @micheleinmichigan

    Sorry, but I had trouble understanding your jab at TILIS. Thanks for explaining it.

    My take on TILIS’s thesis was that paying attention to a discredited source only validates it. Sort of like the news coverage of the Obama birth certificate conspiracy. In this case, I disagree with him because Kimball Atwood hints that he will be presenting a critical analysis of the book. The readership here will be able to avoid reading the book while still getting some insights on its content. I get his point, and it is valid in some cases – but I disagree that this is one of them.

    @TILIS

    I didn’t understand the punchline of your story about children being terrible witnesses. Do I just need to watch “The Painted Veil?” Nonetheless, you had some interesting takes on those historical events.

  25. JPZ, there’s a good chance that I su$& at cryptic jabs and shouldn’t quit my day job.

  26. qetzal says:

    pmoran,

    I don’t know Dr. Kaptchuk at all. I’ll take your word for it that he has some good qualities and has made useful contributions. But I don’t think that should insulate him from deserved criticisms. In fact, as a scientist, he should welcome and attempt to learn from such criticisms.

    He claims:

    …the study results imply that placebo treatment is just as effective as active medication in improving patient-centered outcomes.”It’s clear that for the patient, the ritual of treatment can be very powerful,” notes Kaptchuk. “This study suggests that in addition to active therapies for fixing diseases, the idea of receiving care is a critical component of what patients value in health care.

    No, it does not. He studied a highly artificial situation with very little relevance to actual patient care. To wit – he studied subjects with mild asthma, who were instructed to stop taking their asthma meds, and who then saw the doctor because it was part of the trial schedule. Not because of any medical need. It’s interesting that these subjects reported similar subjective improvement from placebo vs. albuterol inhalers, but it’s not a relevant patient-centered outcome.

    Now, if he did a study where he waited for patients to come in because they actually felt they were having trouble breathing (rather than because they had a scheduled trial visit), and showed that placebo inhalers made them feel better, that would have some clinical relevance. But he didn’t do that. (And probably couldn’t, ethically.)

    I’m afraid Dr. Kaptchuk is jumping to conclusions that aren’t at all warranted by this study. That’s a bias he should try to overcome. (It’s the sort of bias we all have struggle with.)

    Aside to michelleinmichigan,

    I got your meaning without any trouble, if that makes you feel better. ;-)

  27. Tell it like it is says:

    Hi everyone

    A big THANK YOU to those who took time out to read and comment on my post.

    I was certainly NOT condoning the vile practices I cited – in fact – just the opposite. I was illustrating through cold hard facts how people seem to have a desire to fall for a ‘sucker-trick’ and be willing to be ‘suckered in’ – and that – taken to extremes – this can lead to the most diabolical state of affairs imaginable. In the case of sham medicines – the devout believer with a treatable condition that if left untreated could prove fatal – believes in the potion right up to the point of death.

    I pointed out that adults – and therefore adult ‘minds’ – were being suckered by children – children that were readily ‘brainwashed’ and so unwittingly or intentionally told lies that led to the downfall of innocent souls.

    I also illustrated, that despite scepticism on behalf of a person in high authority (the King of Britain), and despite the King’s very sound rebuke to the people in positions of trust such as doctors, Judges – or in the Salem case – a Magistrate – such ‘beliefs’ were (are) still being hawked.

    Sham practices – in all of their many guises are dangerous hogwash. To the enlightened, including the unfortunate sufferers who realise they have been badly stung – in health, purse, and pride – they seek a more rigorous solution that is backed by scientific certainty.

    But sham practices are not just dangerous because they fail to deliver – they can lead to avoidable or premature death. But – just like the belief in witchcraft, juju, vodun, Louisiana voodoo, et al – beliefs based upon fear – there is a much deeper and more sinister morbidity – for perpetrators of, and ‘converts’ to, such vile practices creates ‘medicine based religion’.

    Yes ‘The painted veil’ reveals many veiled (covert) practices. One of these practices has a direct and profound effect on children that affects how they see the world for the rest of their lives.

    Interestingly, witch trials took place in the 17th Century – the ‘age of enlightenment’ that gave us such notables as Sir Isaac Newton, Sir Christopher Wren – and – the most revered scientist and physician of all time – William Harvey.

    In 1634, William Harvey was asked by the King to scientifically investigate allegations put forward by a child from Leicester that would see 17 women hanged for witchcraft if found guilty.

    What Harvey provided was a serious set of tools that would assist the innocent by identifying the guilty – and in so doing – introduced the concept of ‘forensic science’ – seeking lawful truth through science.

    The boy said he had been ‘bewitched’ and turned into a toad by a coven of witches – naming 11 women who had scolded or otherwise reprimanded him for stealing and other dastardly deeds the boy had committed.

    William Harvey was able to conclusively prove that what the boy was saying was a pack of lies; and the women were set free. One of the accused women was Jenit Devis.

    Despite massive progress with forensics during the 17th Century, in 1692 it was the word of a child that led the women at the Salem trial into mortal danger and sealed their fate.

    Despite massive progress with science in this century and the last century, today it is the word of a quack that leads many into mortal danger that seals their fate.

    Evil changes over time. We hear of a young girl incarcerated by a paedophile for 18 years and giving birth to his children; and we read about child killers, drug dealers, and terrorists. This begs the question: “In our modern age of technological comprehension, should we label quacks as evil?”

    As P T Barnum wrote for inclusion in a speech to be given by one of his friends: “You can fool some of the people all of the time, and all of the people some of the time, but you can not fool all of the people all of the time.”

    That friend was George Washington.

  28. woo-fu says:

    @TILIS

    This begs the question: “In our modern age of technological comprehension, should we label quacks as evil?”

    Good question. I suppose it would depend if one were judging based on intention, effect or a combination of the two. Some very predatory people can convince themselves they’re on a healing mission appointed by the All-Mighty.

    By extention, one might ask if true-believers are evil when their religious beliefs thwart the progress of science and learning, or if people practicing (but not truly believing) in religions (alt or “traditional”) are evil for enabling the true believers and their unworkable philosophies. I don’t hold this opinion–that these people are evil–myself; however, I have seen variants of these arguments in the comments here on SBM as well as from noted atheists and agnostics.

    I used to dismiss these arguments because they seemed entirely prejudicial and deliberately ignorant of the concept that not everyone who practices what some here have labeled as “backward religions” rejects science. Many have emotional, familial and social reasons for their practice, so to categorize all religious folk or alt practitioners as anti-science is a straw-man argument at best.

    Furthermore, while in the past much of our superstitious behavior held full reservoirs in some of the pre-scientific practices you name, today a lot of the new agey woo I hear comes from more “acceptable” suburban community churches and megachurches. However, it isn’t so easy use these folk as an example without seeming to be completely anti-religion in general (at least in the U.S.)

    I’m not trying to toss out a golden apple here, but I am interested to know what people think about the issue. The more I am alerted to the encroachment of religious sentiments upon critical thinking and human rights in general in our modern era, the more I am forced to reanalyze my position.

    This leads me to a heavier question, is it possible to be a good doctor and a good scientist, still hold onto whatever religious/philosophical beliefs chosen, and practice science-based medicine free of religious/philosophical bias? I ask because where I live, the Prospertity Doctrine has become an epidemic, even among MDs. I see this as a direct conflict of interest.

    Why bother to help heal someone who has “called in” their illness, an illness some divinity might be using as a punishment or to toughen-up a weak parishioner? On the other hand, there seems no problem for such MDs to make a bunch of money giving these “lesser beings” quack remedies.

  29. pmoran says:

    Qetzal:I’m afraid Dr. Kaptchuk is jumping to conclusions that aren’t at all warranted by this study.

    Supporting what Kaptchuk is quoted as saying in the press release (I agree, rather loosely, if accurate) , there was apparently no statistically significant difference between patient- reported outcomes with albuterol and any of the placebo treatments used. (A larger study might be expected to confirm what looks to be a clear trend towards better results with albuterol).

    I quote –

    However, patients’ reports of improvement after the intervention did not differ significantly for the albuterol inhaler (50% improvement), placebo inhaler (45%), or sham acupuncture (46%)

    This adds to a lot of other evidence showing surprising results from sham interventions under some conditions and in some populations, with this single small study merely helping to confirm that albuterol does what we think it does physiologically, and that placebos don’t in general affect objective results or human physiology.

    Nevertheless it IS weird how impressive the results can seem to be with treatments that “do nothing” when looked at in sham controlled trials. Look at mammary artery ligation, glomectomy for asthma, vertebroplasty, endoscopic debridement in osteoarthritis — and now various other shams for asthma.

    We within SBM prefer to regard this phenomenon as a distracting side-show to the proper business of medicine, or even entirely the product of various illusions. We can certainly explain a lot of it away.

    Others think that it may be a more important aspect of medicine than we allow, and they are producing evidence to support that viewpoint.

    I say let’s see how things pan out.

  30. qetzal says:

    pmoran,

    My point is not to dispute the similarity in patient reported outcomes between albuterol and placebo inhaler. My point is that the outcome being reported is not clinically relevant.

    These weren’t patients who needed treatment for their asthma. These were clinical trial subjects with asthma who were instructed to stop taking their meds. Last I knew, being a trial subject who stopped taking meds – as instructed – is not a medical condition. Sure, they reported feeling better after a placebo inhaler, but so what? They were “improving” relative to a totally artifical situation, and there’s no evidence that how they felt in this artificial situation has any relevance to their disease.

    IOW, Kaptchuk wasn’t actually studying ‘patient-centered outcomes’ so the results don’t tell us anything about them.

  31. pmoran says:

    Qetzal:My point is that the outcome being reported is not clinically relevant.

    IOW, Kaptchuk wasn’t actually studying ‘patient-centered outcomes’ so the results don’t tell us anything about them.

    Nevertheless, as I pointed out, identical results are obtained in clinical studies employing far less artificial scenarios.

    The only surprise here is that the active drug did not stand out more. One explanation for that might be if these researchers somehow perform their studies in such a way as to enhance all the elements that go into placebo responses, thus obscuring such differences.

  32. nybgrus says:

    @woo-fu:

    This leads me to a heavier question, is it possible to be a good doctor and a good scientist, still hold onto whatever religious/philosophical beliefs chosen, and practice science-based medicine free of religious/philosophical bias? I ask because where I live, the Prospertity Doctrine has become an epidemic, even among MDs. I see this as a direct conflict of interest.

    I have made the argument before (here, I think, and elsewhere many times) that one cannot be a good doctor or scientist and have deep seated theistic (or otherwise) beliefs unless your field of research/practice does not conflict with said beliefs. I have never made that statement unchallenged, yet every time someone rebuts the give me example of deeply religious scientists who come up with serious and amazing scientific breakthroughs. However, in each case, the breakthrough is in a field that is not informed upon by that person’s religion. My counter points are simple: Kurt Wise and Georgia Purdom.

    The difficulty I encounter with people refusing to accept that science and religion are incompatible is that they cannot nut out or accept that specific beliefs and the strength to which they are held vary from individual to individual. So when you cite a scientist like Francis Collins and try and assert that proves religion and science can be compatible, they fail to see that Collins’ religion and research do not encroach upon each other – though he did write that book “The Language of God” in which he attempted to explain DNA through theistic eyes. But here we see a situation where he must accept the science and thus molds his religion to fit that. Every example of religious scientists fits that modus operandi but the disingenuous and apologists either willingly or not fail to see the distinction.

    IMO, Kurt Wise and Georgia Purdom are sufficient to demonstrate the incompatibility of science and religion. Wise quite literally faced the cognitive dissonance and outright stated he knew and understood the science, but willingly opted to stick with his beliefs and eschew the science. He stuck his head in the sand and knows he did that. Georgia Purdom is more insidious. She continues to do “science” and call it so, but states quite clearly that if experimental outcomes do not corroborate the bible, then the experiment must have been flawed. And she has a PhD in molecular genetics.

    Couple this with the fact that 85% of the scientists in the NAS are atheist and that closes the argument for me. Anything else is grasping at straws and special pleading.

  33. roadfood2 says:

    “why one earth would you choose nonsense when proven, powerfully effective medical treatments are available?”

    I have a little first-hand knowledge of at least one answer to this. A friend of my wife’s is one of the all-time champion believers in woo. The opposite side of the coin of total trust in nonsense like homeopathy is a very large distrust of conventional medicine. In just a short conversation with this woman, she made it clear that in her mind conventional medicine is *dangerous*. Just look at all the people who have died or gotten horribly sicker on FDA-approved drugs? Natural herbs, on the other hand, are totally safe. And they’ve been proven effective over their thousands of years of use. Oh sure, lots of allopathic drugs are based on herbs or other natural cures, but in the drugs the molecular structure has been altered. Besides, the FDA is a sham, it’s totally in the pocket of the drug companies that care more about profit than safety.

    So you see, what you call nonsense, people like that call the true proven (over thousands of years of use), powerfully effective — and totally safe — treatments. And what we call the proven, powerfully effective medical treatments, they call the less-effective — and dangerous — sham.

  34. BillyJoe says:

    woo-fu,

    There is a simple solution to your dilemma:
    It’s not the believers who are evil but their beliefs.
    So you don’t attack the believers, you attack their beliefs.

  35. Tell it like it is says:

    “Is it possible to be a good doctor and a good scientist, still hold onto whatever religious/philosophical beliefs chosen, and practice science-based medicine free of religious/philosophical bias?”

    A terrific question. I would say the rational person who is ‘pure in heart’ would say YES. I say this because science both supports the views of many religions and the scientific proof stares one in the face – we need only to look to the monk Gregor Mendel.

    On religion: many churches are willing to perform ‘exorcisms’ – a word here which means ‘recite spells to banish away ‘evil’ spirits’. I see this as a required and necessary placebo to support a belief, because if the ‘believers’ are convinced of the ‘existence’ of a ‘super natural’, omnipotent, all-seeing, all-knowing being who stands for ‘good’ then, to balance the books, there has to be a similar ‘super natural’, omnipotent, all-seeing, all-knowing being who stands for ‘evil’ that can be overcome through powerful spells that banish such intrusion. As a result of such pandemic beliefs, many people believe in ‘evil’.

    On ‘beliefs’ and who is at fault – the ‘belief’ or the ‘perpetrators’? I take the stance that it is certainly not the ‘congregation’ of ‘believers’ who are ‘convinced’ who are at fault – unless what they ‘believe’ in and practice is of itself ‘evil’. If that is the case you should attack both the beliefs ‘and’ the believers.

    I would say that:

    If the ‘ministers’ of a particular religion or sect know what they are proclaiming, preaching, and giving as ‘alms’ is bunkum then it is the ‘ministers’ who are at fault.

    If the ‘ministers’ of a particular religion or sect are truly oblivious to the fact that what they are proclaiming, preaching, and giving as ‘alms’ is bunkum, then it is the ‘ministers’ who persuaded them to accept that belief that are at fault.

    By progressing through the ‘belief chain’, as the ‘belief chain’ is traversed, a point will be reached or declared that will reveal who formulated the belief in the first place. We now have the providence.

    From the providence, through dissection of the ‘beliefs’ and associated dogma we can determine credulity or otherwise – and take action according to our drive and commitment to do so.

    As we read here, rational people realise that there is no avoiding the paradox put forward by P T Barnum: “There is no such thing as bad publicity – all publicity is publicity”. But – as much as I enjoyed the thought of a lathe rotating around itself – as opposed to the workpiece ‘on’ the lathe doing the rotating – what was said by Michele et al is no laughing matter.

    Here we have a website that takes a particular (and laudable) stance and makes every attempt to decry and destroy all practices it abhors – and yet – in so doing – this entire website and all of its contributors provide publicity to the very thing they revile.

    Even worse, by reviewing publications that are considered disreputable by this community, in a just attempt to provide an unbiased balance, the reviewers – inadvertently or otherwise – often provide positive statements that will be cited by the adversary to give the impression that the reviewer endorses the content.

    The first ten words on my first comment gave my view on the article, the cited publication, and the broader media – to reiterate: ‘The web has a weaver – of truth, lies, and deceit.’

    It is the truth mingled within the copy that supports the lies through the use of ‘false syllogisms’. These false (silly) syllogisms are then used to drive the deceit.

    Scott put his finger right on the pulse – and provided a ‘silly syllogism’ that – if believed – drives home the deceit – quote:

    ” is effective and superior to conventional medicine.
    only produces subjective responses, while conventional medicine produces objective responses.
    Therefore
    Subjective responses are effective and superior to objective responses.

    It’s the only conclusion that doesn’t require them to admit that their first premise is false.” (unquote)

    Thanks Scott – well put. On ‘false’ I go one step further:

    All remedies make you feel better.

    False treatment can harm you.

    Therefore false treatments that can harm you make you make you feel better.

    Now I would not be so arrogant as to suggest that we all rush out and take the ‘Watson Glaser critical thinking test’ – but I do feel that people are readily duped because they lack the means and wherewithal to critically evaluate what they are presented with and make sound judgements based upon rational evaluation.

    Critical thinking is not taught in schools. We instantly see exploitation of this fact when we visit the local supermarket and read ‘Buy one – get one free’. What they are saying is ‘buy two’.

    Why pay for two when you only need one? In this age of famine, from land-fill statistics, we learn that we throw away 34.7% of our food – but that is another matter entirely – or is it?

    In times of crisis fear leads to exploitation of the vulnerable.

  36. woo-fu says:

    @BillyJoe

    I suppose I was playing a bit of a devil’s advocate, pardon the pun, in posing the question that way–I don’t tend to judge people as good or evil. But, actions, of course, are another matter.

    Regarding beliefs, that’s more complicated to engage debate about in terms of how it affects medical care. I’ve known doctors who I thought were nearly perfect professionals who were also believers. Some did accommodate their beliefs with their scientific knowledge, while others kept each influence separate in working dissociated states.

    I really don’t remember having any religious or philosophical discussions with any doctor (on my dime) in my younger days. This was the majority of my experience until the mid-90s or so. Then, this prosperity doctrine swept through, and everything started to change.

    @nybgrus

    What’s so challenging in discussing this problem is finding a common definition of belief, religion and practice. Many religious practitioners do accommodate science into their beliefs or their beliefs into science. I don’t see this as disingenuous as many feel it is, unless they’re proclaiming to be orthodox true believers at the same time. It’s a good example of how we learn in the first place. New information comes along which may create cognitive dissonance where it (or the prior belief) may be integrated, accommodated, rejected or walled-off (maintaining the dissonance).

    Many religious individuals I’ve known believe religion is a product of humankind and as such should evolve as our understanding evolves. Their beliefs regarding gods or a holy spirit is more abstract, almost heading into that theological noncognitivism territory. To some, these people are not “believers,” but they practice just the same.

    Still, it’s a sticky wicket. Does a patient just have to hope the doc’s personal beliefs won’t interfere with their professional beliefs? This is as important an issue for practitioners of minority faiths as it can be for atheists, non-theists and agnostics.

    @Dr. Atwood

    As an asthma patient who does not get any placebo effect from faux treatments, I’m very glad you and the other contributors here at SBM are covering this so assertively. Sorry for the OT tangent–it just seemed to fit into the discussion and is a major issue in my community.

  37. daedalus2u says:

    I would say that all health care professionals who do not practice SBM are evil. How evil is a matter of degree which depends on how much they do that is not scientifically validated.

    A beneficent intent does not matter at all. To be a professional, one must know the limits of your expertise and practice accordingly; that is practice within areas where the treatments you are providing are known to be safe and efficacious.

    The only way a treatment can be known to be safe and efficacious is if the treatment is tested scientifically and shown to be safe and effective.

    Treatments that have not yet been shown to be safe and effective are experimental treatments and can only be administered by a health care provider in the context of a clinical trial to determine the safety and effectiveness of the treatment.

    It is evil to administer treatments that have been shown to be not safe or not effective while claiming that they are. It is evil to facilitate people who will administer treatments that have been shown to be not safe or not effective while claiming that they are.

    It is evil for a journal to allow articles to be published that purport to show (with smoke and mirrors) that treatments that are not safe or not effective are safe or effective.

    The NEJM is evil for publishing the article and the editorial that are the subject of this blog post.

    The editor of the NEJM, Jeffrey Drazen, has sufficient expertise in asthma to appreciate that the conclusions of Moerman in the accompanying editorial are wrong and dangerously wrong. That he allowed it to be published is evil, the evil that happens when good people do nothing.

  38. DW says:

    “Evil” is a religious concept – this is less than useful. If we’re going to end up calling the New England Journal of Medicine “evil,” clearly, well, not useful.

  39. daedalus2u says:

    I think that evil can be considered in the absence of religious concepts.

    http://en.wikipedia.org/wiki/M._Scott_Peck

    His description of an evil person is pretty close to what I consider evil to be, and yes the NEJM does fit this description if it allows quackery to be credulously published in it in a narcissistic attempt to save face for publishing something so bogus.

    As I see it, the NEJM has a choice. They can deal with the bad and harmful article they published, retract it and be not evil, or they can ignore the justified criticism of it and be as evil as it is.

    Maybe I am being simplistic and don’t understand the difficulties that the NEJM has in rejecting bogus quackery simply because it is bogus quackery. Maybe there are political considerations that the NEJM has to take into account that are more important to them? What part of putting political considerations above patient wellbeing is not evil?

    A face-saving way for the NEJM might be for one or more of the authors to request that it be retracted because it was dangerously misinterpreted by Moerman and the other authors won’t accept a change in wording to make it less ambiguous.

    That at least forces a notice of the problem in the literature, even though it will likely damage the career of the (likely junior) authors who compel it.

  40. DW says:

    Just because the word is used outside religious contexts doesn’t mean its origin isn’t religious. It’s an inflammatory term, it just isn’t useful. Appealing to M. Scott Peck doesn’t help at all; his ideas are hardly scientific. (And while we’re at it, sourcing things to wikipedia is not credible anyway.)

  41. weing says:

    Perhaps he is using the term in the Hobbesian sense as in the Leviathan:

    “Good and evil are names that signify our appetites and aversions, which in different tempers, customs, and doctrines of men are different: and diverse men differ not only in their judgement on the senses of what is pleasant and unpleasant to the taste, smell, hearing, touch, and sight; but also of what is conformable or disagreeable to reason in the actions of common life.”

  42. woo-fu says:

    @TILIS

    I must have missed your reply as I was contemplating my prior comments. Mendel made indisputable contributions as a scientist to advance the study of medicine; however, he did not actually practice as a doctor, did he? If not, he at least did not have to struggle with interpersonal conflicts of interest as an acting physician. But your point is noted.

    Here we have a website that takes a particular (and laudable) stance and makes every attempt to decry and destroy all practices it abhors – and yet – in so doing – this entire website and all of its contributors provide publicity to the very thing they revile.

    Even worse, by reviewing publications that are considered disreputable by this community, in a just attempt to provide an unbiased balance, the reviewers – inadvertently or otherwise – often provide positive statements that will be cited by the adversary to give the impression that the reviewer endorses the content.

    I feel somewhat ambivalent about the assertion all PR is good PR. I can see where you’re coming from, but is the only solution silence? Or does it just mean that those analyzing and criticizing these works must be that much more skilled in how they present their case; so that their words cannot be twisted as easily?

    Now I would not be so arrogant as to suggest that we all rush out and take the ‘Watson Glaser critical thinking test’ – but I do feel that people are readily duped because they lack the means and wherewithal to critically evaluate what they are presented with and make sound judgements based upon rational evaluation.

    I keep working on my critical thinking skills, but sometimes, I let my guard down, or I’m run down and too tired to fully process. Learning those skills is very important, but I think it is also important to recognize that even very skilled thinkers will have their moments of weakness.

    In times of crisis fear leads to exploitation of the vulnerable.

    Agreed! (A greed? Hmmm)

    @daedalus2u

    Obviously I’m no doctor, but isn’t there a code of professional conduct (I’m in the U.S.) that could help prevent such religious/philosophical personal conflicts of interest from affecting medical care? I know this issue has come up several times regarding providing abortion services and end-of-life services where they are legal. I just don’t know if there is one central source for professional expectations or whether they vary from place to place.

    @DW & weing

    Perhaps you are both right. Maybe sticking to legal terms (fraudulent, negligent, etc.) would be more productive in describing what is actually happening.

  43. @woo-Fu I too am inordinately fond of breathing :) Lucky for me, I haven’t had a bad, extended episode of asthma since my first one. My doctor’s office is good about fitting me and offering a good treatment plan the same day I call, if I have a flare not controlled by albuteral. In that sense, I think office management and process are just as important or more important to my outcomes as the particular doctor’s bedside manner.

  44. daedalus2u says:

    DW, no, no, no.

    Just because a term at one time had a religious derivation, does not mean the term is not allowed to be used in a non-religious context.

    I was not referring to Peck as an expert on “evil”, I was referring to him for his definition of the term, a definition which matches (pretty closely) the sense in which I was using it and how it applies to quacks.

    Quacks have their primary focus on themselves and not on their patients. This is the reason they avoid the narcissistic injury that would come from examining critically the treatments they are administering and finding that they are useless. It is to avoid this narcissistic injury that they find that “toothpicks work too”. If your ego is so fragile that you can’t stand being found to have made a mistake, then you have no business trying to be a scientist or to practice SBM. It is to avoid the narcissistic injury of giving and promoting useless acupuncture treatments that compelled Kaptchuk to conclude that subjective relief was just as good as objective relief. Characterizing a treatment with subjective benefits but no objective benefits as equivalent to a treatment with both subjective and objective benefits is dishonest, it is wrong, it is harmful and IMO it is evil.

    Wikipedia is perfectly acceptable to use as a source of a definition of a term in common use. Do you have another source for a definition of “evil”? I have now looked in PubMed and didn’t find anything that was satisfactory. I did find this.

    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3060718/?tool=pubmed

    but that is more on how to cope with evil. That is what shruggies should be doing instead of shrugging.

    I also found this

    http://www.ncbi.nlm.nih.gov/pubmed/10445933

    But that is more focused on wholesale evil rather than the retail evil that quacks produce.

    The thread already had multiple comments by multiple posters questioning whether it was legitimate to refer to quacks as “evil” and also to multiple comments relating the compatibility of religious beliefs to the practice of science and scientific medicine.

    I was agreeing with previous posters as to when treatment modalities (and the practitioners who use them) could be characterized as evil. Whenever the practitioner exceeds his expertise and uses treatment modalities that are not based on science, that practitioner is being evil.

    Evil is an inflammatory term. The practices that can legitimately be characterized as evil are inflammatory too. Quacks saying that just because placebos produce subjective effects similar to medicines that produce objective effects that placebos are “just as good” as the real and effective medicine is an inflammatory statement. It is also wrong, it is also harmful and it is also evil. People who say it are wrong, and if they persist in saying it with the intent of convincing patients to use placebos instead of effective medicine (and so harm them) then they are evil too.

    Weing, and Woo-fu, I have elaborated some on my definition of evil, but am limiting it to the practice of medicine in this context. Fraud and negligence don’t quite meet what I am trying to convey. If you contract to wave your hands over someone for payment, and you do wave your hands over someone, there is no “fraud”.

    The “fraud” and evil is in representing that waving hands over someone will do “something” beneficial that justifies the payment of money. Fraud is a contractual problem. The person who says Dr xyz can poke you with needles and that will cure your asthma has not committed “fraud” per se, even if Dr xyz knows the statement to be false. Moerman hasn’t committed fraud because he hasn’t charged anyone for something he didn’t deliver. Moerman has committed an evil act by equating treatments with subjective and objective effects. If people follow what he says, then people will be harmed. That is evil. Moerman isn’t an MD. He doesn’t have a “duty of care” to any patients, so he can’t be negligent either.

    He has the freedom of speech right to say what ever he wants to say, but then I too have the freedom of speech right to call him an evil POS for saying something so harmful, damaging and dangerous in a journal like the NEJM. I see him mostly as an ignorant POS, I see the NEJM and the actual MDs involved as more culpable and more evil to tolerate and by their consent and inaction to allow this evil to prosper.

  45. woo-fu says:

    @micheleinmichigan

    My doctor’s office is good about fitting me and offering a good treatment plan the same day I call, if I have a flare not controlled by albuteral. In that sense, I think office management and process are just as important or more important to my outcomes as the particular doctor’s bedside manner.

    I hear that! My doc’s office is pretty top-notch, too.

    @daedalus2u

    Fraud and negligence don’t quite meet what I am trying to convey.

    I can see that. I didn’t mean to oversimplify or minimize the impact of the points you are making. And, you’re right, the legal terminology fails with the examples you provide.

  46. DW says:

    Of course the term can be used in a nonreligious context, but if we are looking to counter irrational beliefs, it hardly helps to invoke belief in another irrational force. A belief in “evil” is of religious origin, sorry. It just isn’t a useful concept if we’re aiming to keep our feet on the solid ground of reason.

    Labeling people evil is never going to be useful in combatting mistaken beliefs. It’s simply silly. We all know very well there are people who believe in irrational things or even promote irrational things who are simply not evil. We need to keep our wits about us here.

  47. “The editor of the NEJM, Jeffrey Drazen, has sufficient expertise in asthma to appreciate that the conclusions of Moerman in the accompanying editorial are wrong and dangerously wrong. That he allowed it to be published is evil, the evil that happens when good people do nothing.”

    It IS an editorial, not a research paper. I have heard of there being retractions of papers or articles, but do medical journals usually do retractions on editorials? Editorials are usually considered opinion pieces and the standard disclaimer from most media outlets on opinion pieces is ‘Views expressed in this magazine do not necessarily reflect the opinions of the journals staff or publisher.’

    Usually for newspapers, it is considered desirable to offer a diversity of current, prominent opinions in order to evokes discussion and further thought. One would hope that doctors are capable of discussion and thought and able to see the flaws in the editorial. Of course, space for another editorial with opposing views would be a good thing. More in appropriate than a retraction, I would think.

    But, I an not a NEJM reader, so I’m not familiar with their editorial process. Are the editorials presented as facts rather than opinions? Does the oversight on the editorials suggest that content does, in fact, represent a NEJM approved medical approach?

  48. On evil. Before labeling anyone or any belief as evil, I would like to known the purpose of applying that label.

    One purpose to labeling is to facilitate research or exploration… by labeling a set of symptoms with a name one might more easily study that set of symptoms. But that kind of labeling does not seem relevant to this labeling of evil. Are we studying evil?

    One purpose I seen in using the label of evil is to stir up negative sentiments, dehumanize and even encourage some sort of retribution or violence against the people or belief. That purpose is generally against my values.

    Is there another purpose in this case that I am missing?

  49. DW says:

    Michele, I think you’ve got it, those are basically my problems with the “evil” label as well, though you’ve explained it more clearly than I was able to do.

    I did think more about why I consider evil a religious notion (i.e., not helpful in science-based medicine, or science-based anything). “Evil” posits that there is some actual force in the world that causes bad things to happen or makes people do bad things. It is a spiritual force, generally set in motion by imaginary beings like Satan. It’s as imaginary as ectoplasm, or the soul, or karma. It is not an explanation, it’s an admission that we don’t know the cause of something. (This is also why I find M. Scott Peck thoroughly distasteful; when a therapist ends up deciding his client is “evil,” he’s just admitting he has no idea the cause or solution to the problem.)

  50. DW- I did not read the Peck link, but a therapist deciding his patient is evil sounds pretty yucky, not science based either. What exactly are the objective measures of “evil” We give psychology some slack in the objectivity department, but that seems taking advantage…

    My first inclination was the same as yours, that evil was a religious term. But upon reflection, I do think that the word evil can be used outside of a supernatural context. It is sometimes used to express a reliance on selfish negative instincts (greed, lust, etc). For example Google’s corporate motto is said to be “Don’t be evil.”

    Within that context the term evil is more reliant on having a sense of ethics or values that are not necessarily supernaturally influenced (although one might suggest that the power of google approaches the supernatural :) ) But the label “evil” is used to guide the corporations choices. That seems a useful purpose which I don’t find relevant to passing judgment on another person or group.

  51. daedalus2u says:

    DW, according to Dr Atwood, the editor of the NEJM is not ignorant. Dr Atwood doesn’t think he has mistaken beliefs. I don’t think he has mistaken beliefs either. I think he knows full well that treating the subjective symptoms of asthma is not equivalent to treating the objective symptoms. Why he is allowing such crap to be printed in the NEJM is not about his beliefs about asthma treatment.

    In my opinion, allowing non-technical and non-scientific considerations (i.e. the politics of CAM) to “trump” good clinical science in discussions about patient care is evil. No one who understands the science can possibly think that better patient care will come from ignoring the science and treating subjective symptoms. That is what the Moerman editorial says is ok, treating subjective symptoms and getting subjective relief is ok and is just as good as treating objective symptoms.

    Before the modern era of SBM, all the health care practitioners could treat were subjective symptoms and pretty much all they had to treat them with were placebos, herbs and a few non-specific drugs with terrible side effects such as mercury. Did treating those subjective symptoms with placebos help then? Does Moerman actually think that the only improvement in medical care in the last century is the improved “magnificence of the hospital building”?

    If it isn’t about better patient care, what is it about? What is the agenda of the NEJM to print such things? What is the agenda of the editor of the NEJM to allow such things to be printed?

    If the NEJM wanted a diversity of opinion on the subject, then they would have had editorials that eviscerated the Moreman editorial and the Kaptchuk study. I am not a NEJM subscriber, but my understanding is that they didn’t. Maybe they are saving them for a reply at a future date, but leaving stuff like that uncriticized even for a few weeks is (IMO) unacceptable.

  52. daedalus2u says:

    Regarding evil. Evil was brought up in the thread in the context of things done by humans that are considered evil, genocide, torture, mass murder.

    The reason that many humans consider such evil acts to be a product of a supernatural agent is for those humans to distance themselves from the evil actions and to maintain the self-illusion that they would be incapable of such acts.

    The whole point is to dehumanize the people committing evil acts to maintain the self-delusion that someone “like me” would be incapable of such an evil act and that it requires a supernatural agent to be present to commit such evil. That is why the Pope had to blame the rampant pedophilia in the Catholic Church on the Devil. He couldn’t blame it on the priests who actually did it, or the priests who condoned it, or the priests who knew it was happening and covered it up, because those people are still there and he is one of them. He had to externalize the evil to be able to avoid the narcissistic injury that he would have by admitting that he could condone such treatment of children. That is what Peck’s definition of evil encompasses; a willful ignoring of the harm being perpetrated so as to be able to not experience the narcissistic injury that one is capable of such acts that cause such harm.

    “Normal” people can’t do that, they don’t have the ability to dissociate their actions from the consequences of their actions to such a degree that they can ignore the harm that what they are doing causes. It is that ability to dissociate that allows people to do evil. The ability to do that can be developed and is a major consequence of abusive treatment.

    Nietzsche said:

    “He who fights with monsters might take care lest he thereby become a monster. And if you gaze for long into an abyss, the abyss gazes also into you.”

    My interpretation of this is that to perceive what is in the abyss, one must have pattern recognition instantiated in neuroanatomy to match what is in the abyss and so recognize it. If you try to perceive something, then the neuroanatomy of your pattern recognition will self-modify until you can perceive it. At that point, you have a bit of the abyss in you.

    The concept of evil didn’t go away when people became non-religious.

  53. “Normal” people can’t do that, they don’t have the ability to dissociate their actions from the consequences of their actions to such a degree that they can ignore the harm that what they are doing causes. It is that ability to dissociate that allows people to do evil. The ability to do that can be developed and is a major consequence of abusive treatment.

    I see normal people dissociating themselves from the harmful consequences of their actions all the time. Do you have any evidence that isn’t “normal” behavior? How about Milgrams experiments in obedience?

  54. daedalus2u says:

    Milgram’s experiments are exactly the point. Before the experiment none of the participants would have predicted they would do such things, yet they did.

    When people go into basic training, few of them are capable of killing other people in cold blood. The purpose of basic training is to break-down the normal inhibitions that are present to killing people in cold blood so as to generate killing machines that obey the orders of their superiors.

    In WWII, relatively few soldiers did most of the killing. I don’t have data readily available, but my understanding is that a few percent of soldiers did 80%+ of the killing. In the US, basic training has changed all of that so that a much larger fraction of the soldiers participate in killing. That makes for a more effective military, but it also increases the incidence of PTSD in veterans, something which is not at all addressed.

  55. I guess I don’t see your point DU2. So I remain unconvinced that the label evil is useful or provides any meaningful content, beyond a appeal to emotion, in a discussion of the medical ramifications of Moermann’s (SP?) editorial.

  56. DW says:

    Michele:

    “My first inclination was the same as yours, that evil was a religious term. But upon reflection, I do think that the word evil can be used outside of a supernatural context.”

    Sure it can be, I guess it’s just a question of whether it’s useful. I agree with you in general I can’t see much purpose to it other than stirring up anger.

    daedalus:
    Daedalus, I don’t disagree with you at all about the NEJM, just the label “evil.” I don’t see this as helpful, as I said. Your next post seems to contradict your desire to label them evil:

    “The reason that many humans consider such evil acts to be a product of a supernatural agent is for those humans to distance themselves from the evil actions and to maintain the self-illusion that they would be incapable of such acts. The whole point is to dehumanize the people committing evil acts to maintain the self-delusion that someone “like me” would be incapable of such an evil act and that it requires a supernatural agent to be present to commit such evil. That is why the Pope had to blame the rampant pedophilia in the Catholic Church on the Devil.”

    Exactly, so you’re explaining my problem with the word “evil” better than I did myself, yet you’re insisting the NEJM is evil, so I’m perplexed.

    Ah, perhaps here is the problem – you wrote:

    “Normal” people can’t do that, they don’t have the ability to dissociate their actions from the consequences of their actions to such a degree that they can ignore the harm that what they are doing causes.

    That’s where I’d disagree. As Michele pointed out, “normal” people in fact do this quite regularly. Didn’t you get the import of your own quote above? What you’re doing now is ITSELF dissociative – irony! – you’re claiming other people do this, not “normal” people!
    You don’t seem to see the import of the stuff you posted yourself.

  57. nybgrus says:

    @woo-fu:

    What’s so challenging in discussing this problem is finding a common definition of belief, religion and practice. Many religious practitioners do accommodate science into their beliefs or their beliefs into science. I don’t see this as disingenuous as many feel it is, unless they’re proclaiming to be orthodox true believers at the same time.

    That is exactly why I say that any religious people would be de facto hard pressed to be excellent researchers. We cannot pin down exactly which beliefs they have, how strongly, and when they may come out. But if you are a true believer (which is what we are talking about here – the cafeteria christian or agnostic who marks “christian” on the census just because his parents were don’t factor into this equation) then you must believe in some magical and completely evidence free stuff just for the sake of believing. I think you need to reframe your thought and realize that everyone must be treated as a true believer if they say they are, and those agnostic box checkers don’t matter and are the exception. For me, the difficulty is when I realize that people actually and truly do believe this stuff (any of it) to be 100% true. Your separation of the “orthodox” believers from the “regular” believers is, IMO, not where the dividing line should be.

    Those that accomodate science into their views are simply shaping thier religion around the science. But if, at some point, the science buts up against a part of their belief system that is particularly solid, we will have a problem. BUt that is why an extremely religious and even young-earther can be a great synthetic chemist, for example. I doubt plastic research will greatly affect their beliefs.

    Many religious individuals I’ve known believe religion is a product of humankind and as such should evolve as our understanding evolves. Their beliefs regarding gods or a holy spirit is more abstract, almost heading into that theological noncognitivism territory. To some, these people are not “believers,” but they practice just the same.

    These are the cafeteria theists and cultural theists. They don’t *really* believe and I would doubt many of them are regular churchgoers. This is bordering on the “No True Scotsman” fallacy, I know, but the reality is that if someone thinks their religion is a product of mankind then they really aren’t practicing a *religion* so much as a secularized set of moral codes and actions they derive from a religion.

    Still, it’s a sticky wicket. Does a patient just have to hope the doc’s personal beliefs won’t interfere with their professional beliefs? This is as important an issue for practitioners of minority faiths as it can be for atheists, non-theists and agnostics.

    I agree wholeheartedly. Fortunately, in most cases religion doesn’t really but heads with clinical medicine very much. Women’s health is the major exception – birth control, abortions, etc. But we have heard many a story where a physician has asked patients to pray with him/her, denied care for women wanting birth control or abortions (refused to refer, even), and that is unacceptable.

    There is that old apologist question oft asked in debates – “If you were in a strange city at night, by yourself, walking on the streets and a crowd of people were walking your way would you feel more comfortable if you knew they had just come from church or that they were atheists?” They like to think that the answer would be church-goer because they are so much more moral, kind, and likely to have just, I dunno, finished a quilting circle or something whilst the atheists have no morals or reasons to prevent them from harming you. The reality is though, that I would be more comfortable with a group of atheists. And your questions have clearly shown why – I can’t possibly define what beliefs these particular theists may have and so I would have to be on my toes to make sure I didn’t let slip something that would disagree with their worldview (such as being an atheist myself). Because the moment that happens they feel they have god on their side and I would be less than human. No thanks.

  58. DW “Sure it can be, I guess it’s just a question of whether it’s useful. I agree with you in general I can’t see much purpose to it other than stirring up anger.”

    Yes, we are in agreement, I was just pursuing my mental tangent of a tangent. I occurred to me that in many cases when the phrase evil is used in the secular sense it is applied to large powerful groups such as corporations, governments, conspiracies, etc. In that case, the implication is that the group is acting as a force that is powerful, pervasive and somewhat unknowable…like a supernatural force. Which does not change my conclusion, it’s just sort of interesting to consider that these groups then become a sort of mental surrogate of religious evil (the devil, etc.)

  59. nybgrus “These are the cafeteria theists and cultural theists. They don’t *really* believe and I would doubt many of them are regular churchgoers”

    Sorry, I know this wasn’t addressed to me, but if I might add my experience?

    Actually, many of the people who I know who are regular church goers are these people. Maybe it’s a regional thing. Even the pastor of my husband’s church seems to recognize the large role that humans, culture, politics had in the development of various gospels. This is not presented as a denial of the existence of a god, but in the difficulty in understanding god through the gospel. I don’t know…not my thing.

    Anyway, As a patient, I generally assume that a medical person’s religious beliefs are not a problem unless they come up in a way that raises red flags. I figure there are many possible biases that a person can bring to their profession that could possible create problems. (My dad was a evangelical atheist who seemed to feel that theists of all kinds were stupid, weak or corrupt. That kind of bias wouldn’t be particularly helpful in a healthcare provider) trying to rules them all out is too bothersome, I just try to keep an my eyes open for wackiness of any kind.

  60. nybgrus says:

    always a pleasure to have your input Michele.

    I agree that many of them can indeed be churgoers – I don’t know that there is too much data to support whether that would be “most” or “some” but I don’t think that matters much. The group I am referring to in this case would be the “cultural” theists – the ones that go to church not because they have positive beliefs and conviction, but because everyone else is. That is where the social functions are, were people gather and get help with problems, etc. In other words, it is not because they actively feel some compulsion to go because of their true belief in whatever deity or dogma it is that the church ostensibly ascribes to. I say “ostensibly” because these days many churches are looking to be more “inclusive” and the focus is not so much about the deity and the ritual, but the moral lessons and social interactions.

    However, if you noticed my post was descriptive of mostly “hard” research – not clinical applications. The very nature of clinical medicine – based in science but by necessity requiring patient input and values in integrating an appropriate clinical decision and plan – makes it less likely for religion to become an issue. Of course, it is not impossible, as I had stated above. Everyone has their biases, and in medicine you must learn to check them at the door. The same way that, were I presented with the situation, I would provide medical care to a member of the Westboro Baptist church, despite thinking them to be despicable and vile human beings.

    But indeed, the red flags do happen sometimes, and for reasons based in the nature of the predominant religion in America it tends to happen mostly in women’s and reproductive health. I personally have known a woman who had to suffer because a Catholic hospital would not perform a D+C to remove the already dead 7 month old fetus from her womb and had to find and schedule her own oustide appointment with an obstetrician days later. This was legal since it was a private institution, but IMO unethical from a medical standpoint.

    If the question is “can you provide good clinical medical care if you are deeply religious” then I think the answer is, “for the most part, yes.” If teh question is “can you do good research and good science if you are deeply religious” then I think the answer is almost the same but worse in degree. However, the big difference is that the former is much easier to detect failures than the latter. Bad science and research is difficult to root out and expose. Bad clinical medical care is much easier to spot and identify (for the most part).

  61. Ahh, nybgrus. I did not really get the line you were drawing between the implication in clinical medicine vs research medicine in my previous reading. Thanks for clarifying.

    I think I might have to agree with you. I would guess there is some research in women’s reproductive health that would be a good demonstration of the problems of a direct conflict between a religious belief and science. I don’t have time to do that hunt though.

  62. DW says:

    >There is that old apologist question oft asked in debates – “If you were in a strange city at night, by yourself, walking on the streets and a crowd of people were walking your way would you feel more comfortable if you knew they had just come from church or that they were atheists?”

    I’m a pretty settled atheist, but I dunno, the older I get, the more I find a question like that just silly. I wouldn’t feel one way or another about whether strangers on the street are church goers or atheists – I think the actual data shows the atheists slightly less likely to be dangerous or violent. But in reality I wouldn’t think what their religious beliefs were had anything much to do with whether I ought to feel afraid of them.

  63. DW says:

    Michele -” occurred to me that in many cases when the phrase evil is used in the secular sense it is applied to large powerful groups such as corporations, governments, conspiracies, etc. In that case, the implication is that the group is acting as a force that is powerful, pervasive and somewhat unknowable…”

    Right – we use the term “evil,” it seems, to indicate that we feel helpless against it. We don’t understand it and/or don’t feel we can do anything against it.

  64. DW “Right – we use the term “evil,” it seems, to indicate that we feel helpless against it. We don’t understand it and/or don’t feel we can do anything against it.”

    Yes, and similar to one of your previous statements, the storyline always goes… good fights evil, good cannot compromise with evil, good must seek to stamp evil out. To evoke the word evil is to suggest that extreme measures are our moral obligation. I’m generally not a fan of that.

  65. nybrgus “>There is that old apologist question oft asked in debates – “If you were in a strange city at night, by yourself, walking on the streets and a crowd of people were walking your way would you feel more comfortable if you knew they had just come from church or that they were atheists?”

    I love these kinds of questions. After careful consideration I have to choose “C” birdwatchers. Sadly I can imagine either church goers or atheist turning violent. I feel confident that as long as I am not shooting birds or calling for my outdoor kitty, that birdwatcher are a safe bet. They probably wouldn’t even notice me and as a bonus, if I ask, they’ll probably be able to point out some cool urban owl or bat.

    My husband (the church goer) said ‘atheist, no churchgoer, no I’ll have to think about it’. My son said ‘people with underwear.’ My daughter said ‘Churchgoers, no wait!, I want to be a penguin.”

    Are they apologist for ultra-limited multiple choice questions? :)

  66. DW says:

    “birdwatchers”

    LOL! Absolutely. You joke but actually there’s something to it.

    Actually, if I’m on a street late at night (I’m not, really, but I suppose years ago …) and, for instance, a strange man comes along, and that makes me nervous, I’m definitely relieved if he turns out to be walking a dog. Not only does this suggest he has a good reason for walking the streets, it also suggests he has at least one important relationship in his life, one other creature he cares about in the world, which makes him less likely to be a dangerous or desperate person. This might be a better measure than religious belief or practice …

  67. nybgrus says:

    lol – you guys crack me up. Of course, I do not think the question is particularly good, but it really is brought up a lot in debates – both professional and personal. Rather than say the question is stupid (which would be the answer for 99% of apologists questions) I have started saying that since it catches them off guard. They are so fully entrenched in their belief that being a theist inherently and always makes you morally and ethically superior than an atheist that they cannot imagine such an answer.

    BUt of course you and DW are spot on – there are much better metrics for when you should or shouldn’t be scared by strangers at night. But when confined to the answer choices prompted by this standard apologist question….

  68. daedalus2u says:

    The percentage of atheists in prison is way below the percentage in the population.

    http://www.freethoughtpedia.com/wiki/Percentage_of_atheists

    So, either atheists commit far fewer crimes or they are much more likely to get away with it.

  69. nybgrus says:

    d2u: likely both ;-)

  70. …or atheist who go to prison find religion, either as a comfort or because they think that a affiliation with a religion will look better when the parole hearing comes up.

  71. DW says:

    Wow Michele … that is an interesting twist. There might be something to it. Also, I think inmates get preached at a lot, and I also suspect that there is a lot of peer pressure in prison to reform (though there’s a lot of the other, too), and cleaning up your act is often assumed to include religion. And I would guess you’re right, that if actually ASKED about religious belief, an inmate has quite a vested interest in giving the answer that is thought to be most socially acceptable.

    That’s just speculation of course; would be interesting to research it. Someone should research whether parole boards tend to consist of religious people. I always get the creeps thinking about missionary efforts in prisons, though in reality, they are probably doing more good than harm, since the church truly is a good route to respectability.

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