Apr 08 2009
Dr. Michael Dixon, the medical director of the Prince’s Foundation for Integrated Health, wrote an editorial for BBC news that is a densely packed rant of tiresome straw men often trotted out by the defenders of so-called “integrative” medicine. (The reason for the quotes in the headline, by the way, is because I stole that line from George Will who used in on This Week recently – it was too perfect not to co-opt.) Dixon was responding to an excellent commentary by Edzard Ernst, in which he characterized integrative medicine as a”shabby smokescreen for unproven treatments.”
Dixon was writing right out of the playbook of “integrative” propaganda, so it is worthwhile to expose his numerous logical fallacies and mischaracterizations of fact.
The Holism Gambit
Integrated health is not a new concept – the best doctors and their clinical colleagues have practised it for years.
It means treating patients as whole human beings – paying attention to body, mind and soul – instead of regarding them as nothing more than a set of symptoms to be got out the door as quickly as possible.
If Dixon wishes to be taken seriously by scientific practitioners he should make more of an effort to more fairly characterize mainstream medical practice. Of course, I must acknowledge up front, that there are mediocre and even bad doctors. There are also good doctors struggling within failing systems. And there are also many excellent doctors with effective practices. However, Dixon makes it seem as if the absolute worst of mainstream medicine is standard and typical. This is insulting, dismissive, and frankly ignorant of the facts on the ground. I find it interesting that defenders of integrative medicine are frequently whining about the dismissive attitudes of scientific practitioners of whom they are dismissive.
But the meat of this comment is the attempt to equate alternative or integrative medicine with holistic medicine, and the straw man that scientific medicine treats only diseases and not patients. That is certainly not how I was taught medicine, it is not how I practice medicine, and not the culture of medicine I find around me.
At Georgetown Medical School where I trained (I graduated in 1991) we were taught the “biopsychosocial” model of medicine – which means we view the patient in the context of their biology, their psychology, and their social situation. This was not just a slogan – it was a central part of the clinical culture that we were taught. It is simply a straw man to say that scientific medicine does not consider the whole patient – even 18 years ago this was already being fully integrated into mainstream medicine, before it became fashionable among the promoters of dubious treatments.
For years defenders of scientific medicine have been pointing out that the principles of holism – of biopsychosocial medicine – are already part of mainstream medical culture and ethics. We have common ground on this point. Integrative practitioners did not invent this concept and were not responsible for its adoption into medical practice. This transition happened in the 1970s and 80s after the paternalistic model of medical practice was falling out of favor. Integrative proponents have simply taken this concept and made it their own for propaganda purposes – as Ernst very aptly characterizes as a smokescreen for their real agenda (which we will see below).
But, very much like creationists, defenders of integrative medicine will not let go of an argument even after it has been debunked often and publicly.
The Argument from Final Consequences
Those who campaign against integrated health seem not to understand that there are many conditions and many patients for whom no conventional treatment will offer a complete cure, ranging from back pain to terminal cancer.
For these patients, treatment is about relieving their symptoms, improving the quality of their lives, perhaps helping them adjust to the restrictions their illness imposes.
Does Dixon really believe that scientific practitioners do not understand the limitations of current medical knowledge and practice? Anyone who practices medicine and is not frankly delusional understands this. But the fact that an effective and proven therapy is not currently available does not justify making up fake therapies and offering them to patients.
The second line is downright laughable, and ironic. In my own practice the majority of my interventions are aimed at relieving symptoms, improving quality of life, and helping patients adapt to their limitations (I am a neurologist). I find it hard to accept that Dixon actually believes that scientific practitioners do not routinely provide symptom relief for those with incurable illnesses. Again, this is a huge and rather transparent straw man.
It is also ironic because another favorite criticism of proponents of unscientific medicine is that science-based medicine focuses on treating symptoms and does not treat underlying causes (another straw man). This claim is often brought out when promoting a bizarre theory of all disease, for example the straight chiropractic claim that all illness is caused by the block of flow of “innate intelligence” or life force.
Ethics vs Science
Dixon descends further into his fray with an imaginary army of straw men:
Those who aggressively oppose integrated health forget that it is the patient who should ultimately make the decision on their treatment, whether that is conventional or complementary or a combination of both.
Dixon really needs to familiarize himself with common logical fallacies. This statement is a straight up non sequitur – Dixon confuses the ethics of informed consent and patient autonomy with the scientific basis of medical treatments. Medical ethics already dictate that patients are in control of their own medical decisions. Also, as I said above, the old paternalistic model of “doctor knows best” has been gone for a generation. The current model of practice is one of patient collaboration and informed consent.
In the modern model of medical practice the physician is an expert adviser, and decisions are made in collaboration with the patient, who is in ultimate control of their own medical decision-making. In practice patients defer to varying degrees to their physicians, according to their own inclinations. And again, there is a broad spectrum of practice styles among physicians and many fall short of the ideal. But the standard of practice is clear.
I would add that while patients decide their own health care they do not have a right to demand unethical treatment from their physician. They cannot force a physician to write a prescription, perform a procedure, or make a referral that they think is unethical or bad medicine.
And again I find this straw man to be ironic, for it is the promoters of unscientific medicine who are violating the ethics of informed consent by giving their patients false, misleading, or partial information and advice.
After distracting his readers with a long and typical list of straw men that have nothing to do with reality, Dixon gets to the real agenda behind his smokescreen – arguing for the use of unscientific modalities. That is what it is all ultimately about – using treatments that are scientifically implausible and lack evidence for safety and efficacy.
But first he has to set up the usual tu quoque logical fallacy – to argue that evidence-based medicine is not so evidence-based either. He writes:
Why? Quite simply because there is no evidence for many conventional treatments. One scientific review found that of 2,500 commonly used conventional treatments, effectiveness was “unknown” for 46%.
Well, at least he didn’t cite the ridiculous 15% figure that is based on a 40 year old terrible survey. But he is still cherry picking his citations. There are actually several reviews that aim to answer the question of how many mainstream practices are based upon scientific evidence. A more thorough review of such studies shows that more like 78% of medical practices are based upon reasonable scientific evidence.
But again Dixon makes the mistake of confusing what happens in the field vs the accepted standard to which we should all be striving. The goal should be (certainly advocated by SBM) to have the best scientific evidence and plausibility behind every treatment and intervention. The public is best served if we make continual efforts to increase the level of scientific evidence for medical practices. That we fall short (by whatever amount) does not justify abandoning the scientific standard itself.
As with most editorials promoting unscientific medicine (whether you call it integrative or CAM), the long string of logical fallacies, diversions, and factual errors ultimately lead to the same bottom line – an appeal to use modalities that are not based upon scientific evidence. Dixon writes:
Patients are not lab rats on whom “science” can impose its will.
Evidence is there to serve the patient, not the other way round.
Here he is bashing science in the guise of defending patient freedom. But elsewhere he gives us more insight into his philosophy:
And the test is not whether someone has carried out a scientific trial, but whether the patient’s condition improves.
And there you have it – the appeal to anecdotal evidence over scientific evidence. It always seems to come eventually, in some form. Proponents of unscientific medicine are very clever in phrasing this appeal in many ways, trying to disguise its essence. But it always comes down to the same thing – the patient’s anecdotal experience trumps scientific evidence. Sometimes they come right out and say it, and other times, like here with Dixon, they are very coy. But the appeal is the same.
Of course, this statement is entirely absurd. It assumes the very question at hand – does a treatment actually work? Is it safe, and do its benefits outweigh its risks? Dixon is foolishly assuming that a treatment works simply because it seems to work, or because a patient believes it has worked. However, a couple of centuries of careful observation has taught us that anecdotal experiences are very deceiving, and are not to be trusted.
In fact we developed the technology of scientific clinical trials specifically to control for the weaknesses of anecdotal experience. Clinical trials are designed to control for as many variables as possible, to control for placebo effects, and to eliminate the biases and desires of the researchers, practitioners, and their patients. The goals of scientific trials is to obtain the most reliable patient evidence possible and to avoid self-deception.
Dixon is dismissive of “scientific trials” as if they are limited to something that happens in a petri dish, ignoring that clinical trials involve real-world outcomes in actual patients – just under carefully controlled observational conditions. Therefore he gets it exactly wrong – the test is whether or not a treatment is safe and effective when observed under controlled scientific conditions, and not anecdotal experience which is inherently misleading.
In a separate interview Dixon was apparently more clear about his position. The Telgraph interview reports:
The efficacy of complementary treatments, he (Dixon) insists, simply cannot be measured by standard scientific “double-blind” tests in a lab.
This is the old “your fancy science cannot test my claims” gambit. But again, this is just an excuse for those treatments that cannot be shown to work under scientific conditions – because they do not work. They likely do not work because they are based upon bizarre, outdated, or simply wrong ideas. They are at odds with how nature actually works, so it is no surprise that they do not work. Even putting aside their extreme scientific implausibility, the evidence shows that most modalities promoted by Dixon as integrative and rejected by scientific medicine simply do not work.
This conversation between promoters of SBM and promoters of unscientific medicine is reminiscent of the conversation between creationists and scientists (and for those who think I am just poisoning the well with that comparison, I think it is an apt analogy on many levels). Dixon and other “integrative” proponents have their script, and they are sticking to it. And why not, it seems to be working to some degree. But their straw men are just that, and so they are talking past scientific practitioners. If they keep beating their “holistic”drum they should not expect any science-based practitioner to take them seriously. They are attacking nobody – a fiction of their own propaganda – so why should they expect anyone to listen.
And Ernst is exactly correct – their straw men are just a smokescreen for the promotion of scientifically dubious claims.
In order to move this conversation truly forward we need to first agree on some common ground: Treating the whole patient is good – we all agree with biopsychosocial medicine. Patients are partners in their own health care and deserve informed consent. For patients who cannot be cured treatment should focus on relieving symptoms, improving quality and duration of life, and optimizing function. (I feel like I am lecturing to a first year medical student.)
I will go further to say that preventive medicine is very important. Physicians should emphasize and encourage lifestyle practices that promote health and prevent disease. Nutrition and physical therapy have important roles to play in overall health care. Physicians should practice rational pharmacotherapy and need to be very cautious about polypharmacy and overprescribing.
OK – can we call get past these points now? We agree. This is already part of good modern medicine. Stop arguing against positions nobody holds.
But now we need to push the common ground further. Medical interventions should be based upon the best scientific knowledge available. This means that treatments have to be scientifically viable (not completely understood, but just not in violation of the basic and well-established laws of physics, chemistry, and biology). And they need to be based upon high quality evidence.
We should further agree that anecdotal evidence is low-grade evidence. It should be used as a guide to future research only, and not as an ultimate method of deciding what works and is safe. Better evidence always trumps weaker evidence. And we should not make the excuse that a treatment cannot be studied scientifically.
If we can all agree on these principles, then there would be no need for any “alternative” or “complement” and nothing to “integrate.” There will be no double standard in medicine – just one science-based, ethical, and holistic standard.
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