Mar 07 2008
The Best Policy
From time to time I have been reiterating that correct use of the language has much to do with logic; I should add that it entails also honesty. I use the word “honesty” in its broadest sense…
Concision is honesty, honesty concision—that’s one thing you need to know.
—John Simon. Paradigms Lost: Reflections on Literacy and its Decline. New York, NY: Clarkson N. Potter, Inc.;1980. pp. 48, 52
In 1983, a naturopath in Alberta inserted balloons into the nostrils of a 20 month-old girl and inflated them. The child died of asphyxiation. Subsequently, a judge described the treatment—dubbed “bilateral nasal specific” by the chiropractor who had invented it—as “outright quackery.”  Fast-forward 15 years: a woman presented to the otolaryngology clinic at the University of Washington in Seattle “complaining of severe midface pain and epistaxis” (nosebleed). She had suffered nasal septal fractures caused by a similar treatment, by then renamed “NeuroCranial Restructuring” (NCR). In their case report, the surgeons who had treated the woman at U. Wash discussed the claims of NCR and explained that the relevant anatomy predicts that it is implausible and risky. They also reported that it is expensive: “$2000 to $4800 for a standard course (of 4 treatments).” They concluded:
This case report of a complication after a CAM procedure called NCR highlights the wide range of treatment options available to patients. It is important for otolaryngologists to be aware of the spectrum of CAM therapies that patients may pursue and be aware of potential complications from these procedures.
An accompanying editorial used similar language.
How is it that in 1983 a judge could offer a concise summary of the essence of such a method, whereas scarcely a generation later 5 highly-trained medical doctors, even after presenting the sordid facts, could only obscure it with bland euphemism?
Language Distortions: why “CAM” requires quotation marks
I recall having first seen the term “language distortion,” referring to promotions and apologies for implausible medical claims, in a 1998 article written by our fellow blogger Wally Sampson: “The Braid of the ‘Alternative Medicine’ Movement.”  In offering explanations for the popularity of “CAM,” Dr. Sampson described the various motivating factors as being intertwined, as are the strands in a braid. One of those factors was
Propaganda and Language Distortion
We now see a new use of an ancient tool used by experts at manipulation of the public mind. Even the words “holistic,” “alternative,” “complementary,” “unconventional,” and “unorthodox” are invented euphemisms intended to mislead. They are benign terms covering a vast array of practices—most of them unproved, dubious, disproved, absurd, and fraudulent. Any politician knows one must find an enemy, even a straw one, to win elections. The term “slash, burn, and poison” was invented by Laetrile advocates to demean ethical cancer medicine, and it worked and it stuck.
In a strange twist of the braid, constructivist sociologist-historians of medicine in an “alternative medicine” journal have already turned the tables on our analysis of language distortion and accused rationalist scientists’ use of realistic terms like quackery, misrepresentation, and fraud of being merely prejudicial and biased. They call for more neutral terms to describe absurd methods like homeopathy. Thus the strands of constructivism and propaganda complement each other in the braid.
In addition to the language distortions applied to the bizarre treatment described above, there are numerous other examples in the world of “CAM.” They follow a strikingly similar time course:
- In 1989, “chelation therapy” for atherosclerosis made the FDA’s list of Top 10 Health Frauds. By 2001, the NIH was calling the treatment a form of “alternative medicine.”
- In a series of editorials in the 1970s and ’80s, the editor of Archives of Internal Medicine and Chest called chelationists “pseudoscientific zealots” who were “abusing a precious freedom.” By 2001, an NIH protocol referred to those zealots as “prominent experts.”
- In 1984, Representative Claude Pepper convened a Congressional Hearing entitled Quackery: a $10 Billion Scandal.  Nine years later, an article in the New England Journal of Medicine trumpeted a similar dollar figure as the annual out-of-pocket expenditure by Americans for “unconventional therapies”—a collection of practices similar to those that had been portrayed as “quackery,” and their collective monetary cost as a “scandal,” by the Pepper Report. The lead author of the NEJM report later called the same practices “varieties of healing” and expressed his approval of the monetary costs by parlaying his findings into promotions of the practices and their practitioners.
- In 1995, the Federation of State Medical Boards (FSMB) established a “Special Committee on Health Care Fraud.” In 1999, the committee’s name was changed to the “Special Committee on Questionable and Deceptive Health Care Practices.” In 2000, the committee appears to have vanished—to be replaced by the “Special Committee for the Study of Unconventional Health Care Practices (Complementary and Alternative Medicine).” That committee, aided by 3 consultants from academic “CAM” programs (one of whom was the first author of the NEJM report cited above), issued a report in 2002 that effectively reversed previous attempts to discourage physicians from practicing quackery. It also violated the FSMB’s formal policy of promulgating the Code of Ethics of the American Medical Association (AMA) for the purpose of “improving the quality of care…and appreciation of medical ethics” (to be cited next). The 2002 FSMB “CAM” report has since been accepted by numerous state medical boards.
- Since at least 1977, the AMA Code of Medical Ethics has acknowledged that science-based medicine is not only a matter of competent practice, but also of honesty (quoted in part; emphasis added):
E-3.01. Nonscientific Practitioners. It is unethical to engage in or to aid and abet in treatment which has no scientific basis and is dangerous, is calculated to deceive the patient by giving false hope, or which may cause the patient to delay in seeking proper care.
E-3.04. Referral of patients. A physician should not so refer the patient unless the physician is confident that the services provided on referral will be performed competently and in accordance with accepted scientific standards and legal requirements.
The AMA has not re-worded those tenets. As we’ve seen, however, the FSMB and several state medical boards have. Here is how the FSMB “CAM” report—citing the National Center for Complementary and Alternative Medicine (NCCAM)—defines treatments that have no scientific basis:
Complementary and Alternative Therapies in Medical Practices (CAM)
CAM refers to a broad range of healing philosophies (schools of thought), approaches and therapies that mainstream Western (conventional) medicine does not commonly use, accept, study, understand, or make available. A few of the many CAM practices include the use of acupuncture, herbs, homeopathy, therapeutic massage, and traditional Oriental medicine to promote well-being or treat health conditions. People use CAM treatments and therapies in a variety of ways. Therapies may be used alone, as an alternative to conventional therapies, or in addition to conventional, mainstream therapies, in what is referred to as a complementary or an integrative approach. Many CAM therapies are called holistic, which generally means they consider the whole person, including physical, mental, emotional and spiritual aspects.
At the risk of belaboring the obvious, I’ll “deconstruct” that statement. The dominant theme is question-begging. “Healing,” “therapies,” and “to promote well-being or treat health conditions” assume a characteristic that the authors of the statement couldn’t have known to be true, i.e., that the methods in question actually work. That conclusion is readily demonstrable, even to the naive, by the statement’s having emanated from the NCCAM—thus identifying the methods as among those that the NCCAM has deemed in need of clinical trials.
“Holistic” also begs a question, albeit one that may escape the comprehension of the naive: homeopathy can’t be holistic, because it eschews pathophysiology in favor of “symptoms,” and for many other reasons; Traditional Chinese Medicine can’t be holistic because it knows nothing of the nervous system, the endocrine system, cells, anything at the molecular level, and more; chiropractic can’t be holistic because it clings to its “subluxation” theory and its theory of “nerve compression” leading to all manner of systemic “dis-ease,” against all evidence; naturopathy can’t be holistic because it readily accepts all three of the aforementioned claims, along with almost any other implausible claim that comes along, and ignores overwhelming evidence to the contrary. And so forth, for every “CAM” claim there is. “Holistic,” like many other terms and phrases common to “CAM” promotions, is an advertising slogan.
Another language distortion in the FSMB statement is the standard mislabeling of modern medicine by two devices: misrepresentation and derogation. Thus “conventional” is mildly derogatory, implying that modern medicine is boring and uncreative. “Western” is similarly derogatory in this era of neo-romanticism. It is also misleading, because modern medicine is no more ”Western” than the physics of Einstein is “Jewish.” The FSMB statement spares us the misnomer “allopathic,” which is ubiquitous elsewhere and is both derogatory and erroneous.
“Western (conventional) medicine” apparently displays its calcified resistance to innovation by its refusal to “commonly use, accept, study, understand, or make available [CAM].” Question-begging there, too.
Please indulge me now in contrasting the definition of “CAM” quoted above with a concise definition:
A spectrum of implausible beliefs and claims about health and disease. These range from the untestable and absurd to the possible but not very intriguing. In all cases the enthusiasm of advocates vastly exceeds the scientific promise.
What about the term “Complementary and Alternative Medicine” itself? Like the Moral Majority, it is neither. Need it be said that “alternative medicine” implies an alternative form of medicine that works? Many of us in the “CAM”-skeptic crowd have made fun of such misnomers, so there are plenty of useful examples to choose from and it’s easy to think of more. I’ll quote a couple that I’ve found amusing. This is from Bob Baratz, the president of the National Council Against Health Fraud:
To get to the National Institutes of Health in Bethesda from DuPont Circle I can take a cab or the Metro, I can walk or even ride a bicycle. These are true “alternative” methods of travel. However, no matter how hard I wish, or whatever I may choose to believe, I can’t ride a magic carpet or self-levitate to Bethesda.
Physicist John Farley takes on “integrative,” but his points are equally valid for “complementary”:
Suppose that the “integrative” approach were to spread beyond medicine, and were to be more broadly adopted by other disciplines in the sciences. The biologists would “integrate” creationism with Darwinian evolution, while the chemists would integrate alchemy into modern scientific chemistry. The geologists would integrate the belief that the world is only 6000 years old (and flat) with modern dating of rocks. Physicists would integrate perpetual motion machines with the conservation of energy and the laws of thermodynamics. And the astronomers would integrate astrology and astronomy. Of course, this is ridiculous. It’s not a good idea to integrate nonsense with valid scientic knowledge.
Bob Baratz might be wrong, however, according to guest blogger Mark Crislip; and our fellow blogger Steve Novella has shown how “alternative” thinking might be “integrated” into engineering. Who says this crowd isn’t innovative?
It is impossible to mention events such as those described at the beginning of this essay without considering other aspects of the “CAM” debacle. In a legal twist almost as bizarre as the “medical” treatment itself, the judge in the Alberta case sentenced the naturopath to only a $1000 fine and 1 day in jail.  I don’t know enough about the case to explain this, but I suspect that it was due to the naturopath having been a “licensed health care professional.” Edzard Ernst’s words ring true—”the most meticulous regulation of nonsense must still result in nonsense”—and so do mine: “The endorsement of such practices by a state naturopathic licensing board…demonstrates that licensing NDs doesn’t protect the public. Rather, it shields quackery from the scrutiny of the law.”
Is it really possible that there is a licensed health care profession that approves of inflating balloons in the nasopharynx to effect a “controlled release of the connective tissue tension to unwind the body and return it toward to its original design?” Yes, there is. It is “naturopathic medicine,” licensed in Washington and about 15 other states (soon in yours, if you don’t watch out). The method that killed the toddler was taught at least as recently as 2001 near Seattle at Bastyr University, the flagship of naturopathic “medical schools,” and licensed “naturopathic physician” Dean Howell offers to teach “NCR” in 7 days, for a mere $10,000, to naturopaths, chiropractors, medical doctors, osteopaths, and dentists.
Perhaps the ENT surgeons who treated the woman at the University of Washington can be forgiven for their language misdemeanors, which were minor compared to the grand larceny of truth perpetrated by their colleagues in the Department of Family Medicine:
The philosophical approach of naturopathic medicine includes prevention of disease, encouragement of the body’s inherent healing abilities, natural treatment of the whole person, personal responsibility for one’s health, and education of patients in health-promoting lifestyles. Naturopathic practice blends centuries-old knowledge of natural, nontoxic therapies with current advances in the understanding of health and human systems. The scope of practice includes all aspects of family and primary care, from pediatrics to geriatrics, and all natural medicine modalities…
And so on.
Next week: Misleading Language Part II: the Advanced Course
 Butler K. A Consumer’s Guide to Alternative Medicine. Buffalo, NY: Prometheus Books; 1992:82.
 Sampson W. The Braid of the ‘Alternative Medicine’ Movement. Sci Rev Alt Med 2;2:4-11 (Fall/Winter 1998)
 Quackery: A $10 Billion Scandal, Hearing before the Subcommittee on Health and Long-Term Care of the Select Committee on Aging, House of Representatives (98th Cong., 2d sess., 1984). Comm. Pub. No. 98-463
The Misleading Language and Weekly Waluation of the Weasel Words of Woo series:
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