Jun 15 2009
As a physician and scientists who’s dedicated his life to the application of science to the development of better medical treatments, I’ve often wondered how formerly admired scientists and physicians fall into pseudoscience or even generate into out-and-out cranks. Examples are numerous and depressing to contemplate. For example, there’s Linus Pauling, a highly respected chemist and Nobel Laureate, who in his later years became convinced that high dose vitamin C could cure cancer. Indeed, Pauling’s belief that high dose vitamin C could cure the common cold and cancer fueled the development of a whole new form of quackery known as “orthomolecular medicine,” whose entire philosophy seems to be based on the concept that if some vitamins are good more must be better. In essence, “orthomolecular medicine” is a parody of nutritional science; indeed, its advocates take credit for how some strains of “complementary and alternative medicine” (CAM) so frequently advocate the ingestion of huge amounts of dietary “supplements.” I could even go farther and say that orthomolecular medicine is clearly a major part of the “intellectual” (and I do use that term loosely) underpinning of the various biomedical treatments for autism that Jenny McCarthy and Generation Rescue advcoate.
There are other examples as well, all just as depressing to contemplate. For example, consider Peter Duesberg, a brilliant virologist who in the 1980s was widely believed to be on track for a Nobel Prize; that is, until he became fixated on the idea that HIV does not cause AIDS. True, lately he’s been trying to resurrect his scientific reputation with his interesting and possibly even promising chromosomal aneuploidy hypothesis of cancer, but, alas, true to form he’s been doing it by acting like a crank. Specifically, he sees his hypothesis as The One True Cause of Cancer and disparages conventional thinking as having been so very, very wrong all these years (with his being, of course, so very, very brilliant that he saw what no one else could see). Then there are people like Dr. Lorraine Day, who was a respected academic orthopedic surgeon in the 1980s. In the late 1980s, she started to flirt with AIDS pseudoscience through a scare campaign about catching AIDS from aerosolized blood. Of course, given the mystery and fear over HIV in the early years of the epidemic, such a fear, although overblown, was not so far out of the mainstream as to be worthy of the appellation crank. However, after being diagnosed with breast cancer, unfortunately Dr. Day rapidly degenerated into a purveyor of rank pseudoscience, as well as a New World Order conspiracy theorist, religious loon, and Holocaust denier. And let’s not forget Mark Geier, who, although not a distinguished scientist, did, before his conversion to antivaccinationism, apparently do a real fellowship at the NIH and appeared to be on track to a respectable, maybe even impressive, career as an academic physician. Now he’s doing “research” in his basement, injecting autistic children with a powerful anti-sex hormone drug and abusing epidemiology. There are innumerable other examples.
About a year ago, I saw a good discussion by a blogger by the ‘nym of ERV discussing how scientists can become cranks, and I’ve been meaning to expand upon it for a long time now. Since there didn’t appear to be anything happening this weekend that so inspired me to post, and Steve Novella already discussed recent articles in the AP about CAM and how, after an investment of over $2.5 billion, the National Center for Complementary and Alternative Medicine has failed to validate even a single CAM modality and, worse, how all of the negative studies of CAM coming out of NCCAM have failed to lead to the abandonment of even on CAM modality. In any case, as gratified as I am to see the mainstream media to be taking notice and starting to say the same sorts of things we’ve been saying on this blog since its inception, for instance, my discussion of the waste of taxpayer money on studies of homeopathy, among other magic. And, of course, Tim Kreider wrote an excellent takedown of Sharon Begley’s apparent belief that publication pressures and an insistence on basic science are keeping cures from sick babies, the other topic that caught my fancy.
Because her interest is HIV research, ERV was particularly interested in how a brilliant man like Peter Duesberg could have fallen so far into pseudoscience. However, because she is a basic scientist, her view lacks a bit when it comes to why physicians become cranks or quacks. Consequently, I thought I’d expand a bit on this topic and bring a medical perspective to the question. Because I am both a surgeon and a scientist, I routinely straddle both worlds (sometimes not being taken seriously in either). I’m not sure that this gives me any special insight, but it does give me a different perspective than ERV.
First, ERV shows great insight in pointing out that scientists are wrong all the time. Indeed, science can almost be defined as a system or a method of self-correction that brings us closer to an understanding of how nature works. An absolutely essential part of science, therefore, is that we scientists must test our hypotheses and try to falsify them. When we attempt to do so, we find, in general, one of three results:
- The hypothesis is not falsified.
- The hypothesis is falsified.
- The results are not sufficiently clear to falsify or support the hypothesis.
When a hypothesis is not falsified, generally scientists will either try to find new ways of falsifying it until they are satisfied that it can withstand all reasonable challenges. Alternatively, they will build on it and refine it based on their experiments, after which they try to falsify the new iterations of the hypothesis until they succeed. If the initial hypothesis is falsified, scientists generally will move on to a new hypothesis. True, they may not do so quickly or easily; after all, scientists are human too and just as prone to becoming emotionally attached to their pet ideas and favorite hypotheses, but move on they generally do–eventually. Admittedly, in the case of medicine it sometimes takes the rise of a new generation of physicians and the retirement of the old before older concepts of disease completely disappear from medical practice, but disappear they eventually do. (The wag in me can’t resist pointing out one exception to this rule: aalternative medicine, where prescientific ideas dating back hundreds, if not thousands, of years have been resurrected into seeming respectability under the mantle of “complementary and alternative medicine” or “integrative medicine,” which “integrates” these prescientific notions with scientific medicine. But, as I so often do, I digress.)
Of course, result #3 is the most common result; the answer is usually not immediately clear. Indeed, this uncertainty may persist for years, if not decades, before some scientific questions are resolved. this is what can happen with true scientific controversies (as opposed to manufactroversies, like whether vaccines or mercury in vaccines can cause autism). Once again because scientists are human, they can be quite rancorous, on rare occasions even escalating to the point of scientists yelling “bullshit!” at each other at seminars and scientific meetings. (Such meetings can actually be kind of fun, at least if you’re not at the receiving end. Actually, they can sometimes be fun even if you are at the receiving end.) Over time, however, evidence will accumulate, and experimental results will start pointing towards an answer. Sometimes a dramatic result, a stroke of genius, like Einstein’s Theory of Relativity or Charles Darwin’s Theory of Evolution by Natural Selection, will appear, seemingly like a bolt out of the blue and change everything. (I say “seemingly” because even such results do not appear in a vaccuum; there are almost always multiple scientists working along similar lines and it’s scientists like Einstein or Darwin who either publish first or somehow become the person given the most credit.) However it happens, though, once a hypothesis is roundly falsified by multiple lines of evidence (or, as in the case of the autism/vaccine link, numerous studies fail to find support for a link), scientists will indeed, even if very reluctantly, admit that the hypothesis was incorrect, form a consensus, and then move on to test other hypotheses. Or, as ERV put it:
Now here is where we get to the kook part– Say we finally determine that MMTV does not cause any kind of breast cancer in humans. All the normal scientists on the ‘MMTV causes cancer’ side will say ‘Aw. Man. Oh well, my bad.’ and keep doing science. Admitting youre wrong in science is not a big deal because scientists are wrong all the time!
Perhaps the best illustration of this attitude among scientists was a tale told by Richard Dawkins in The Root of All Evil? about an elderly and esteemed scientist who had held to a certain hypothesis for many years. One day a visiting professor from America came to give a talk and presented evidence that conclusively refuted this professor’s favorite hypothesis. As the lecture concluded, all eyes were on the esteemed senior scientist whose favorite hypothesis had just been roundly shown to be incorrect. According to Dawkins, the old professor strode to the podium, shook the speaker’s hand, thanked him profusely, and said, “I have been wrong these fifteen years.” In response, the audience applauded uproariously. Whether this story is apocryphal or not or whether it’s grown with Dawkins’ retelling it over time, it is nonetheless the ideal towards which science strives. Scientists are supposed to be willing to give up even their most cherished hypotheses if that’s what evidence and experimental results demand. Of course, the difficulty in doing so tends to be proportional to both the length of time the hypothesis has been cherished and the intensity of attachment. Now, here’s where “scientist” transitions to “kook”:
Where one transitions from ‘scientist’ to ‘kook’ is the inability to say ‘I was wrong’ and move forward. In the 1980s, Peter Duesberg could have been right! No one knew what was causing this scary-ass world-wide epidemic. Yeah, it might have been HIV-1, but in the US it could have been a side-effect of some recreational drug, only surfacing when use was wide-spread and intense enough. Duesberg could have been right!
But as time went on, evidence stacked up on the side of the ‘HIV-1–>AIDS’ people, and nothing supported the ‘drugs–>AIDS’ people. If Duesberg were a scientist, he could say ‘Ek. Im wrong. Good on you all.’ and continued his career.
Indeed, assuming that Duesberg had done this before he had burned too many bridges with his colleagues by so harshly criticizing and insulting those whom he perceived as part of what he dismissively called the “orthodoxy,” it probably would indeed have been “no harm no foul,” and Duesberg would have resurrected his career and remained a happily well-funded scientist doing important research, rather than a tenured crank working in crappy basement laboratory on a shoestring budget. Heck, even after Duesberg had burned a lot of those bridges, he probably could have rebuilt them with some really good science leavened with just a little diplomacy directed at those whom he had previously attacked. But he didn’t, because, like all cranks, he had become so enamored of his hypothesis that he was unable to let go of it even after the contradictory evidence had become overwhelming. He had become convinced that he was right and the world of HIV scientists were (and continue to be) oh so very wrong.
The other point that is worth emphasizing is that being a contrarian is not in and of itself particularly impressive because scientists are so often wrong. There are far more hypotheses that are falsified than hypotheses that stand up to experimental and observational scrutiny. Indeed, I find “contrarian” scientists who won’t support their doubts of the established consensus with good science (and sometimes not even good logical arguments) of their own to be particularly annoying, like a two-year old who says “No!” to everything. Being “contrarian” is only productive if the contrarian scientist can produce actual evidence using sound experimental and observational methodology suggesting that the consensus is seriously wrong. That’s one reason why “intelligent design” creationists (or, as I’ve increasingly started calling them, evolution denialists) are not taken seriously and should not be taken seriously. They point out what they see as “shortcomings” in evolutionary theory, some valid but most based on gross misunderstandings of what evolutionary biology actually says, and do no research. Indeed, they don’t even try to do any research that might suggest alternatives. The same is true of cranks of all stripes, including “alt-med” cranks, HIV/AIDS denialists, and many other varieties.
So basically the key ingredients of a scientific crank are an inordinate attraction to an idea or hypothesis to the point that he won’t abandon it in the face of overwhelming evidence coupled with the arrogance necessary to believe that he is correct and the rest of the scientific community is not. This is probably true no matter what sort of science is being abused. However, when it’s medical science that leads to outright quackery, there are other issues that come into play.
The first thing that one needs to take into account when considering the evolution of a medical crank is that most physicians are not scientists. As much as it pains me to admit it, sadly it’s true. Indeed, I have lamented time and time again how little training in the scientific method most medical students and residents receive. This makes all too many physicians very susceptible to pseudoscience because they don’t have a good grasp of what good scientific methodology is, and I’ve provided ample examples of this in this blog, perhaps most prominent of which is Dr. Jay Gordon, who rejects the science and epidemiology that have failed to find a detectable correlation between either mercury in the thimerosal preservative that used to be in vaccines or vaccines themselves and autism in favor of his “personal clinical experience,” to the point that he frequently shows up on TV as a “vaccine skeptic” and writes articles arguing against holding anti-vaccine parents legally responsible if their child infects another. In other words, he favors anecdotes over science and, no matter how many times I’ve tried to convince him how easily we as humans can be deceived into confusing correlation with causation or into thinking that a useless treatment works, he cannot seem to accept that he can be deceived as easily as you or I.
Indeed, from my perspective the sine qua non of crank is a certain arrogance. Among medical cranks in particular, this arrogance manifests itself in the failure to acknowledge just how easily all humans, including them, can confuse correlation with causation, engage in selective memory such as confirmation bias, and are fooled by anecdotes, personal experience, and regression to the mean. I can understand how this can happen. Even among people steeped in the scientific method, it is sometimes hard not to fall prey to these shortcomings in human cognition. It is this tendency that will lead them to liken themselves to Galileo, persecuted scientists who will someday be vindicated. They will invoke Ignaz Semmelweis, whose evidence showing how handwashing could greatly reduce the rates of pueperal fever in the obstetrics wards was initially rejected by much of the medical establishment, and the more recent example of Barry Marshall and Robin Warren, who discovered that most duodenal ulcers were caused not by acid but by an organism called H. pylori.
Of course, the case of Semmelweis is more complex than usually proffered by cranks in that he was hesitant to publish and present his results and tended to antagonize his critics, coupled to the lack of an explanatory mechanism for his observations, given that his discovery was made before Pasteur’s germ theory of disease, leaving only the “contagion” concept as a possible explanation. The case of Marshall and Warren is also not a good example in that, although there was initial skepticism of their results, in actuality Marshall and Warren essentially won the day within a decade, by which time the standard of care for treating duodenal ulcers had evolved to using antibiotics. Since then, ulcer surgery has declined to the point where fewer and fewer surgeons even know how to do it anymore except in the case of emergencies (such as perforation or bleeding), so rarely is it necessary. That’s actually an incredibly fast about-face for medicine, given how long it typically takes to bring an idea from bench to bedside. In any case, even if we view the cases of Galileo, Semmelweis, and Marshall and Warren were exactly as described, examples of iconoclast scientists triumphing over the orthodoxy, that would not support the quacks who like to invoke them. As Michael Shermer once said, “Heresy does not equal correctness.” Shermer also correctly put it in his book Why People Believe Weird Things (a book I highly recommend to anyone interested in improving his or her critical thinking skills):
For every Galileo shown the instruments of torture for advocating scientific truth, there are a thousand (or ten thousand) unknowns whose ‘truths’ never pass scientific muster with other scientists. The scientific community cannot be expected to test every fanstastic claim that comes along, especially when so many are logically inconsistent.
Or, as Robert Park put it:
Alas, to wear the mantle of Galileo it is not enough that you be persecuted by an unkind establishment; you must also be right.
Cranks want to claim the mantle of Galileo without evidence to show that they are correct.
The second thing that needs to be considered is that there is a component of being a physician that doesn’t exist for basic scientists that provides added impetus to the transition from scientist/physician to kook, and that component is direct interactions with patients. This component is a powerful contributor to physicians becoming what Prometheus likes to call them, “brave maverick doctors.”
Consider this: Despite what many who do not like “conventional” physicians say, the vast majority of physicians go into medicine because they want to help people. They honestly want to help their patients, and not being able to help their patients causes them intense feelings of inadequacy and disappointment. In other words, there is a strong incentive, both positive (to get that fantastic feeling we get when we realize that we’ve really helped a patient) and negative (to avoid that feeling of inadequacy and frustration that we get when we cannot help a patient), to find treatments that the physician perceives to help patients. There’s also the ego gratification that comes from patients telling one that he’s great and has helped him enormously. The problem with this desire, however noble, is that it makes physicians very susceptible to the siren call of pseudoscience in the form of quackery. Here’s why. “From the ground,” a single physician looking at a group of his or her own patients being treated with a therapeutic modality will almost always “see” that the therapy “works.” The reasons, of course, include the placebo effect and regression to the mean. Without a controlled clinical trial, the placebo effect will almost always bestow upon almost any therapeutic modality at least the illusion of therapeutic efficacy, particularly at the single practitioner level. Thus, it is not surprising that homeopathy, reiki, acupuncture, and all manner of modalities that clinical trials show to be no more effective than placebo can easily appear to be effective when a single practitioner does what is in essence an uncontrolled, single-arm observational trial by treating patients with these modalities. Add to these human tendencies a significant financial incentive, and one can see how the slide into quackery can start out as an exercise in idealism, with “start out” being the operative phrase.
For example, for all the venom I’ve dripped on Dr. Mark Geier (venom he richly deserves for using powerful antiandrogenic drugs on autistic children), I have little doubt that he probably honest believes that he is helping autistic children with his “Lupron protocol,” as autism is a condition of developmental delay, not stasis. Many autistic children improve simply with growth and development, and without a control group and controlled, blinded randomization it’s impossible to tell whether a given intervention leads to an improvement in symptoms over and above what would have occurred anyway. Unfortunately, this belief has led them into some incredibly unethical activities in the service of their belief that they are somehow “helping” autistic children and with the claim that they “know” it works. Indeed, it is rather interesting to read Dr. Geier’s statement in defense of Clifford Shoemaker, a lawyer who has made a cottage industry of bringing complaints to the Vaccine Court, in which he complains of Kathleen Seidel’s activities against his pseudoscience as though he’s a poor, persecuted crusader for good. Of course, poor crusaders for good rarely charge the exorbitant fees that Dr. Geier charges or skirt human subjects research ethics the way he does, but in his world-view he is a lone iconoclast fighting the good fight against an unyielding orthodoxy.
This is where physician cranks (i.e., quacks) then become just like cranks of all scientific stripes, the sole exception being that their crankery endangers patients. They no longer try to falsify hypotheses or do trials to figure out if their remedies work. Why should they? They know to the very core of their being that they work! Instead, such physicians cherry pick studies that support their idea and, if they do any clinical studies or science at all, it is almost universally bad science. Over time, they come to believe that they are right “because I see the evidence in my patients,” as quacks like to say, a statement echoed in the statement of a nonphysician like Jenny McCarthy, who has been widely quoted as saying that her son Evan “is my science.” They forget utterly how easy it is to be fooled by a combination of the placebo effect, expectation, confirmation bias, and observation effect when one is a single physician treating patients. Whether it’s preexisting arrogance or a developed arrogance, these physicians will then often dismiss as “sheeple” the physicians who practice science- and evidence-based medicine as lacking the vision that they have, all the while making excuses for not doing rigorous clinical studies that would confirm or disprove the efficacy of their remedies over and above a placebo. Some, like Dr. Rashid Buttar, will charge enormous fees for their services and think it justified to the point that when they are questioned about the evidence supporting their therapies they will dance around the question and when they are finally brought in front of medical boards for their activities they will behave as an aggrieved, persecuted party, sometimes even going so far as Dr. Buttar as referring to the medical board as a “rabid dog.”
I tend to consider physician-cranks to be almost a special case of scientific cranks in general. In no other field of which I’m aware can the combination of an attraction to a hypothesis and arrogance combine with an honest desire to help patients in a manner that is so toxic to both science and patients. For most scientists, the forces that seduce them into pseudoscience are largely a combination of intellect and arrogance. For physicians, a genuine concern for patients and the placebo effect enter into the equation to form a perfect storm that can tempt them into even the most indefensible pseudoscience.
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