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Egnorance is Bliss

A few years ago, at a skeptics conference in Los Angeles, Stephen Barrett of Quackwatch had just finished giving a talk and was fielding questions from the audience. Someone asked, “why don’t you ever talk about how dangerous regular medicine is?” Dr. Barrett, with a look of bewilderment in his face and a tone of exasperation in his voice, replied: “This is what I do.” That was his way of responding to a question that had nothing to do with his talk, as should have been obvious to both the questioner and the rest of the audience. The question might as well have been “why don’t you ever talk about global warming”?

If people are going to enter the fray of debate, at least they ought to play by the rules. One who doesn’t is the Intelligent Design apologist Michael Egnor, a nice counter-example to the popular myth that neurosurgeons are necessarily intelligent. I’m aware that Steve Novella posted the day before yesterday in response to Egnor’s recent lament about our close friend Orac and about Dr. Novella himself. I couldn’t help but stick in my two cents, however, because deconstructing Egnor’s essay is like shooting fish in a barrel, and it seemed appropriate for Boxing Day. I have avoided reading Dr. Novella’s piece so as not to color my own thinking, so please forgive any redundancies (speaking of that, I’m not the first to make the obvious pun of Egnor’s name). My post will be short and sweet and sour.

In his first paragraph, Egnor claims to agree with Dr. Novella and Orac that there is no scientific basis for most “alternative medicine” practices or for “the view that vaccines cause autism.” Other than his calling modern medicine “traditional medicine,” which means roughly the opposite of what Egnor must have intended, there is little to quibble with. So where’s the beef? Oh:

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

Ho hum: we get a strawman (“defenders of science”), a false premise (“iatrogenic” referring to chiropractors, etc.), a code word (“paradigm”) for BS, and that Mother of all Annoying Fallacies, the tu quoque. Why, Dr. Egnor, would you change the subject? There are many things in this life that are dangerous and that deserve the attentions of thoughtful people—asteroids on collision courses with the Earth, for example, or whether Al Quaeda continues to pose a threat to US territory. You don’t ask Orac and Dr. Novella to address those. Why not?

That’s about all there is to it, for those of you who like to stick to the point.

For those who want to venture, Egnor style, there’s plenty. He asserts that “The data is [sic] uncontestable,” linking to an article by Gary Null posted on the website of Joseph Mercola (makes you think twice about whether Egnor was being honest in his first paragraph). This is the same article that Harriet Hall wrote about in June and that Peter Lipson and various commenters discussed a couple of days ago, so I’ve only a little to add. What are those uncontestable data?

Each year in the United States, errors of traditional science-based medical practice kill at least a hundred thousand people, probably substantially more.

The Null article puts the number at a minimum of >700K, based on flights of fancy (“malnutrition” is said to cause >100K deaths/year; it’s hard to imagine how medical doctors could be causing that). Even the numbers trumpeted by the famous 1999 IOM report—48K-98K deaths/yr—are far from uncontestable. Consider that the two extremes were extrapolations from the only two “studies” that the IOM considered: small, retrospective chart reviews, neither of which had even attempted to establish cause. A more honest summary would have been “48K or 98K deaths possibly associated with ‘adverse events’,” but that might have looked a little too contestable.

Others provided more reasonable interpretations of those data (here, here, and here), suggesting that a realistic number of preventable deaths due to medical misadventure was at least an order of magnitude lower than the IOM estimate. Those perspectives have been mostly forgotten in the wake of media sensationalism. Also usually forgotten, especially by advocates of implausible medical claims, is the issue of risk vs. benefit, which is only meaningful when benefit>0.

Egnor, therefore, makes the same unsupported claim that everyone from Mercola and Null to Newt Gingrich has gleefully made, echoed by self-flagellating, South Park voice-overs from many in medicine proper:

The harm done by traditional [sic] practitioners of medicine is one of the leading causes of death in the United States.

Then he calls Steve and Orac “hypocrites” for not being similarly whiny and for supposedly not caring about real medical errors. Not that any of this matters, of course, because it is irrelevant to the arguments against pseudomedicine.

Egnor builds more strawmen: that our protagonists “excoriate” people who genuinely, if mistakenly, believe in woo; that they have “no respect for the right of people to hold other views,” and so on. That such claims are false (and, if he really wants our heroes to get whiny, approach being actionable) is demonstrated here , among other places.

Near the end of his silly essay, Dr. Egnor reveals his real agenda:

We are beset by an arrogant medical and scientific priestcraft, eager to call ordinary people “idiots” or “anti-science” or “deniers” because they hold viewpoints with which these particular scientists and physicians disagree. I believe that much of the motivation for the “pro-science” priesthood isn’t patient safety or a genuine respect for scientific method but ideological hegemony. What bothers materialist ideologues like Novella and Orac is that there are people who challenge their materialist scientific worldview. There is a deep arrogance to the commentary and tactics of these defenders of science.

Hmmm. Which will it be, Dr. Egnor: science or religion? That question seems to have you chronically stumped, even if you aren’t aware of it.

Posted in: Science and Medicine

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19 thoughts on “Egnorance is Bliss

  1. DLC says:

    Dr Egnor does seem to have lost touch with reality.
    Oh, and . . . I’ve been throwing around “Egnorance” (meaning one who is willfully ignorant of the facts) on Orac and Dr Novella’s blogs. I like it.

  2. David Gorski says:

    I call this syndrome the “why don’t you write about what I think you should write about?” disease. It’s always a distraction away from the point under discussion, nothing more.

  3. PostSynaptic says:

    “If people are going to enter the fray of debate, at least they ought to play by the rules. One who doesn’t is the Intelligent Design apologist Michael Egnor, a nice counter-example to the popular myth that neurosurgeons are necessarily intelligent. ”

    –Kimball Atwood

    Seriously?

  4. Dr Benway says:

    The “mainstream medicine kills” meme is shifting the subject. But it’s more than that.

    Because the distiction between “mainstream” and “alternative” medicine is often not defined explicitly, the boundary is elastic and can be made to mean whatever the speaker would like it to mean.

    If you asked a naive reader of Egnor’s piece, “What’s the difference between mainstream and alternative medicine?” you’d likely hear, “Mainstream medicine has a lot of treatments with dangerous side effects whereas alternative medicine is usually pretty safe.”

    But of course this distiction doesn’t hold up. Treatments with minimal side effects are welcome among “mainstream” practitioners. And alternative practitioners do not eschew all treatments with potentially dangerous side effects.

    Along with the “dangerous vs. safe” reframe we often hear, “Mainstream medicine is under the control of BigPharma, whereas alternative treatments involve herbs and other things that you can’t patent.”

    But mainstream doctors prescribe many inexpensive, off patent treatments and some alternative treatments are proprietary and quite expensive.

    I can think of only one rational basis for the “alternative” vs “mainstream” distiction: alternative treatments have not yet been proven effective, whereas mainstream treatments have some published peer-reviewed evidence in their favor.

    I’d ask Dr. Egnor how he defines this boundary between alternative and mainstream medicine.

  5. Karl Withakay says:

    Even if we were to let ourselves fall into the straw man trap here, Egnor is looking at the numbers wrong. Isn’t risk all about relative risk. Shouldn’t he be looking at the rate of injury relative to numbers treated? Additionally, he provides no frame of reference, such as the same rate of injury for CAM treatments for the same medical conditions

    We’ve had far fewer Americans died in space shuttle accidents since 1980 than we have had die in automobile accidents, so space shuttles would appear safer, but statistically you’re safer traveling by car than by space shuttle.

    If we were going to engage in a discussion of the safety of scientific medicine, gross injury numbers are useless without knowing what percent of the total treatment numbers those injury numbers comprise a subset of.

    The large number of incidents of medical misadventure every year come out of a much more massive number of medical interventions, most of which don’t result in medical misadventure.

  6. weing says:

    I think we should constantly point out that there are 2 kinds of medicine, MM and FM. Mainstream medicine (MM) is science based and fraudulent medicine (FM) is not.

  7. Prometheus says:

    Lovely post, Dr. Atwood. I’d like to make just a few comments.


    “…deconstructing Egnor’s essay is like shooting fish in a barrel…

    I would say that “deconstructing [Dr.] Egnor’s essay” is more like shooting fish that have been taped over the muzzle of a gun. When shooting fish in a barrel, there is always the chance – no matter how remote – that you might miss. With Dr. Egnor’s writings, almost any sentence will contain at least one factual or logical error.

    Secondly, I’d like to point out a fallacy imbedded in the “Myth of Iatrogenic Deaths” – that all iatrogenic deaths are the result of a failure of “modern medicine”. Iatrogenic deaths – no matter what the number or proportion – consist of four very different general causes of death:

    [1] Errors – events where a wrong therapy (or no therapy) was used because of an error in judgement (e.g. choosing medical management of a surgical problem) or a mistake (e.g. grabbing penicillin when you meant to grab erythromycin).

    These are not impeachments of “modern medicine”, per se, but are the result of using fallible humans to deliver health care.

    [2] Adverse reactions – events where the patient had an unexpected adverse reaction to a therapy. [Note: if it had been anticipated (i.e. if the patient had been known to react adversely to a therapy), this would then be an error]

    Adverse reactions are an inherent part of using medications and other therapies that have real physiological effects. If we limited medical treatments to those that had no real physiological effect, we could largely eliminate this category of iatrogenic morbidity and mortality, although it would be at the cost of not actually doing anything for the patient, apart from emotional support.

    Many “alternative” therapies have an inherently low risk of adverse effects (e.g. homeopathy, which also has a very low “risk” of helping the patient more than placebo) while the risk of adverse effects from other “alternative” therapies is largely unknown because there is no requirement that they be reported.

    Dr. Egnor’s claim that he has never known a patient to be injured by chiropratic is disingenuous; as a neurosurgeon, he should at least be aware that chiropractic manipulation has resulted in paralysis and stroke.

    [3] Infections – infections acquired during a hospital stay are a large part of iatrogenic morbidity and mortality in most surveys.

    Although Dr. Egnor mentions in passing the need to wash hands, the reality is that even handwashing cannot prevent all infections – else there wouldn’t be any post-operative infections. The unanswered (and usually unasked) question is how many of the people who died from (or were sickened by) hospital-acquired infections would have avoided such infections if they had remained at home.

    As a microbiologist, I am aware that hospitals harbour many multi-drug-resistant bacteria, so this is not simply idle speculation. These bacteria persist in hospitals despite the best attempts to eradicate them and arose (and continure to arise) as the result of evolution, a concept that Dr. Egnor reduses to countenance.

    The question is whether patients are better served by going to a hospital and taking the risk of infection by bacteria that have evolved antibiotic resistance or by being treated – presumably at home – by a doctor or “alternative” practitioner.

    [4] Accidents – events, apart from medication and treatment errors, that are unplanned and lead to injury and eventual death of a patient.

    A good example of this is the patient who slips in the hospital and falls, breaking a hip, leading to prolonged confinement to bed, a venous thrombosis, pulmonay embolus and death. The slip and fall was the proximate cause of death in that it set the rest of the train of events in motion.

    I’m not sure that you can use in-hospital accidents as an indictment of “modern medicine”, either, since accidents are part of the “human condition” wherever we may be. To be sure, some medications and surgical interventions can make patients more prone to accidents, but so also do alcohol and sports cars.

    The bottom line, as I see it, is that many – if not most – of the so-called “iatrogenic deaths” are due to things that cannot be blames on “modern medicine”.

    Finally comes the Great Unasked (and Unanswered) Question: would there have been fewer deaths if all the patients who submitted themselves to “modern medicine” had used “alternative” therapies instead?

    Would the heart attack patients have done better with a chiropractor or naturopath than they did with a cardiologist? Would the patients with early breast or colon cancer have lived longer if they went to an “energy healer” or a “liver fluke zapper” instead of a cancer surgeon or oncologist? Would a child with hydrocephalus have done better with a homeopath than with a neurosurgeon?

    I’d love to hear Dr. Egnor’s answer to those questions.

    Prometheus

  8. mandydax says:

    While I was reading Karl Withakay’s comment about relative risk, it struck me how homeopathy’s main tenant, that dilution makes it stronger, could be true!

    Homeopathic remedies, being just water, haven’t any side effects, so when more people use them, there are fewer side effects per capita in the CAM modalities as a whole. Increase in use of homeopathy and other placebo-only-type CAM is correlated to a proportional decrease in side effects.

    Of course, taking my tongue out of my cheek, I have to point out that the greater cause of harm from CAM is mostly from dissuading patients to seek effective treatments that could actually benefit them. I hope I never end up on Dr. Egnor’s table; no matter how skilled, I’d prefer someone with a firm grip on both reality and scalpel.

  9. Mjhavok says:

    It is amazing that someone can be so educated that they become a neurosurgeon but still write such an illogical hodgepodge of a essay.

    At the extreme end this reminds me of Islamic extremists who can be so educated that they become doctors but still crash planes into buildings or cars into airplanes.

    Irrational and illogical believes to hurt and sometimes kill.

  10. Joe says:

    mandydax on 26 Dec 2008 at 7:11 pm wrote “Homeopathic remedies, being just water, haven’t any side effects, so when more people use them, there are fewer side effects per capita in the CAM modalities as a whole.”

    An unpublished survey showed that 1/3 of OTC homeopathic preps contain active ingredients (often, caffeine; sometimes potent drugs) to make them effective.

    The same is also true for “dietary supplements” and herbal preps. http://www.fda.gov/bbs/topics/NEWS/2008/NEW01933.html

  11. hatch_xanadu says:

    Exarrctly. Tu quoque considered, the keyword here is ERRORS. “Science: ur doin it rong” does not negate the efficacy of science. Pseudoscience, on the other hand, has the potential to harm even when done “right”.

  12. wertys says:

    Remind me never to have a brain haemorrhage when I’m passing thru Stony Brook NY, as I do not want ‘Dr’ Egnor operating on my cerebrum…..

  13. clgood says:

    Whatever the number, I’m sure that medical errors kill many. The reason we don’t ban doctors, though, is because that number pales beside the number of people helped or cured.

    Speaking of taping fish to the muzzle, I see similar Egnorance in the gun debate, completely ignoring how many crimes are prevented and lives saved by armed with the correct self-defense tools. That number far exceeds the number crimes committed by those who use those tools irresponsibly.

    Back on topic, no matter how easy it was to plug the fish thanks for a great post. Goes to show that logic ain’t brain surgery.!

  14. pmoran says:

    Those engaged in debates with alt. supporters will have found that any reference to the risks of alternative methods elicits this tu quoque response concerning the risks of convenitonal doctoring. The thrust is that we are applying a double standard.

    We can point out that to some extent there SHOULD be a double standard. Herbs and other “supplements” need to be extremely safe because they are available over the counter in any amount to persons of any level of intelligence, to be used unsupervised for any condition. They need to be safer than prescription drugs and medical procedures, intended to used by (hopefully) well-trained practitioners in selected cases where it is believed that the benefits will outweigh the risks.

    The same principle applies to treatments used by alternative practitioners. Stroke from neck manipulation is a major concern primarily because so little of that procedure’s very extensive use by chiropractors can be medically justified.

  15. pmoran says:

    It can even be argued that it is sometimes more important that a remedy be safe than efficacious.

    This notion goes against the uaual precepts of “working better than placebo” science-based medicine. Yet there is a matter that I have never seen raised within skeptical circles that is in my view integral to any full understanding. of medicine.

    There is ample evidence for extreme compulsive behavior in the public consumption of medical products and services. Health economists have known of this for decades. “Alternative” medicine can be viewed as largely sustained by it.

    In general, the public takes it for granted that if you are ill you take something for it or smear something on it or see someone about it. Most don’t give much prior thought to how necessary or even fruitful treatment might be for extremely common ailments such as colds and minor musculo-skeletal disabilities or injuries. It is just something you are conditioned to do from childhood. .

    Can people be conditioned out of it? Probably not completely. Doing nothing is not even the norm in less obviously medical contexts, as is shown by massive consumption of stimulants like tea and coffee, soporifics such as alcohol, and illegal drugs of all flavors, also the extraordinary take-up of anxiolytic drugs such as Valium when they were more freely available, not to mention the popularity of the latest version of the “pick-me-up” or tonic, the vitamin supplement.

    Clearly everyone wants to feel better and to enjoy life more, with fewer handicaps, and a large section of the population will try anything that might remotely help on the flimsiest of recommendations and with little regard for risk . We are even built in such a way that we can feel considerably better for actions that we merely THINK might be good for us, whether that is true or not.

    Should healthfraud skeptics be concerned that at this end of medicine there is a serious mismatch between what the public seeks with considerable determination, and what “working better than placebo” science-based medicine is able to provide with adequate safety at this point in its evolution?

    I am thus curious as to what the objectives of the members of this blog are in relation to some obviously safe but improbable “alternative” methods . Are those objectives clear, realistic, rational — and even entirely science-based?

    (Much of this also applies to the other end of medicine, where people are having to cope with serious diseases. Here, somewhat patchily, the mainstream does have treatments with varying degrees of effectiveness in risk/benefit terms, yet the public is often equally averse to “there is nothing much more that can be done” if that point is reached. There are, however, important differences to this scenario and different approaches would certainly apply.).

  16. Fifi says:

    pmoran – Thanks for the fantastic post – I appreciate how you look at medicine as a human practice and take into account the quirks of human nature. It can be easy when talking about ideas or arguing points to forget that medicine is ultimately about treating people. It makes more sense to me to support medicine that’s created for people than trying to make people conform to an ideal model.

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