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Plausibility in Science-Based Medicine

A question that arises often when discussing the optimal role of science in medicine is the precise role of plausibility, or prior probability. This is, in fact, the central concept that separates (for practical if not philosophical reasons) science-based medicine (SBM) from evidence-based medicine (EBM).

The concept featured prominently in the debate between myself and Dr. Katz at the recent Yale symposium that Kimball Atwood recently discussed. Dr. Katz’s treatment of the topic was fairly typical of CAM proponents, and consisted of a number of straw man derived from a false dichotomy, which I will describe in detail below.

I also recently received (I think by coincidence) the following question from an interested SBM reader:

What would Science Based Medicine do if H. pylori was not known, but a study showed that antibiotics given to patients with stomach ulcers eliminated symptoms? I assume that SBM wouldn’t dismiss it outright saying that it couldn’t possibly be helping because antibiotics don’t reduce stomach acid. I assume a SBM approach would do further studies trying to discover why antibiotics work. But, in the meantime, would a SBM practitioner refuse to give antibiotics to patients because he doesn’t have a scientific explanation as to why it works?

This is the exact type of scenario raised by David Katz during our discussion. He claimed that strict adherence to the principles of SBM would deprive patients of effective treatments, simply because we did not understand how they work. This is a pernicious straw man that significantly misconstrues the nature of plausibility and its relationship to the practice of medicine.

Plausibility

Plausibility is essentially an application of existing basic and clinical science to a new hypothesis, to give us an idea of how likely it is to be true. We are not starting from scratch with each new question – which would foolishly ignore over a century of hard-won biological and medical knowledge. Considering plausibility helps us to interpret the clinical literature, and also to establish research priorities. But plausibility is not the ultimate arbiter of clinical truth – it must be put into context with clinical evidence, just as clinical evidence must be put into the context of scientific plausibility.

One common mistake when considering plausibility is to reduce it to a false dichotomy – a claim is either plausible (which is falsely equated to scientists understanding its precise mechanism of action), or implausible (which is falsely equated to not knowing the mechanism of action). Rather, at least three broad categories need to be considered with regard to plausibility.

The first category are those treatments with a known mechanism or mechanisms of action that should, according to our existing models, produce a certain clinical effect. For example, we know that beta blockers bind and inhibit beta receptors in the heart and on blood vessels and thereby reduce cardiac output and dilate arteries which lowers blood pressure. It is therefore very plausible that beta blockers would have a protective effect against syndromes that result in an excess of catecholamine (adrenalin) production, since catecholamines bind and activate beta receptors.

We may also add to this category treatments for which there is anecdotal or preliminary evidence for efficacy – clinical plausibility.

There is still a range of plausibility within this category, but in such cases there is at least some reason to think that a treatment should work. The core principle of EBM, however, is that even in such situations we still need clinical studies looking at net health effects to show that plausible treatments are safe and effective – plausibility is not enough.

The next broad category is not implausible, but neutral or unknown with respect to plausibility. For such treatments we have no particular reason to think that they should work, but no reason to suspect that they do not or cannot work either. This category would include any pharmacological substance with an unknown mechanism of action, or mechanisms that are not known to interact with the disease or symptom being treated. There is no reason to think that beta blockers would improve memory in dementia, but this is not inherently implausible. Beta blockers are drugs, and may have other effects that have not yet been discovered.

This category applies to the question above – if we had reliable clinical data that showed antibiotics worked for ulcers, even though we had no idea how, we would still accept and even use this treatment (assuming the clinical data was sufficient). This of course would then lead to further investigation – is the beneficial effect due to a pharmacological property of the antibiotic not related to its antibiotic effects, or are some ulcers perhaps caused by or exacerbated by a bacterial infection.

Dr. Katz argued that SBM eliminates the possibility of serendipity – discovering new treatments by accident through clinical observations. But this is simply not true (one of his straw men) – SBM considers all the evidence, clinical and basic science. If clinical evidence is solid, that is enough, and often in the history of medicine lead to discoveries about mechanism and biology.

The arrow of research can go both ways – understanding plausibility can lead to new treatments, but discovering new treatments can lead to discoveries about biology and mechanism. The two play off each other.

But there is a third category in the plausibility spectrum – treatments that are inherently implausible. These are treatments that not only lack a known mechanism of action, they violate basic laws of science. Homeopathy violates the law of mass action (a basic principle of chemistry), the laws of thermodynamics (extreme dilutions maintaining the chemical “memory” of other substances), and all of our notions of bioavailability and pharmacokinetics.

Homeopaths therefore substitute any notion of chemical activity with a vague claim about “energy” – but this just puts homeopathy in the category of energy medicine, which is just as implausible. Invoking an unknown fundamental energy of the universe is not a trivial assumption. Centuries of study have failed to discover such an energy, and our models of biology and physiology have made such notions unnecessary, resulting in the discarding of “life energy” as a scientific idea over a century ago.

Essentially any claim that is the functional equivalent to saying “it’s magic” and would, by necessity, require the rewriting not only of our medical texts, but physics, chemistry, and biology, can reasonably be considered, not just unknown, but implausible.

Dr. Katz and others would like us to believe that this category does not exist, based upon the premise that we do no yet understand enough science to make such judgments. They often invoke vague references to quantum mechanics or the counter-intuitive nature of subatomic physics or cosmology to make their point. But this is an anti-intellectual and unscientific approach – it denies existing knowledge.

The alternative (often another false dichotomy and straw man) is not that we know everything – no one claims that. But not knowing everything is not the functional equivalent of knowing nothing. We do know stuff, and it is folly to deny the accumulated knowledge of the last few centuries of organized science.

Having said that – even the most implausible claim can still prove itself with sufficient clinical evidence. If homeopathy actually worked, it could be demonstrated through repeated rigorous clinical studies (something which has never happened). Admittedly, the bar for such evidence would be as high as the prior implausibility of the claim – which is very high – but if it really worked, that bar of evidence should theoretically be reachable. In that very hypothetical situation, the results would be extremely intriguing – clearly there would be something fundamental missing from our understanding of the relevant areas of science – a situation that often results in Nobel prizes.

Conclusion

SBM is ultimately about achieving the optimal relationship between science and the practice of medicine. SBM requires considering all the science, in its proper context, and does not follow any simplistic algorithm as is often suggested by critics. We look at what is known and what is unknown, at basic science and clinical evidence, and we put it all together, making an individual judgment for each individual claim.

We also are students of history – what claims have prospered or failed in the past, and what patterns predict ultimate success or failure? One pattern that should be obvious is that of highly implausible claims (not merely unknown) that can only produce weak and preliminary evidence, where more rigorous evidence tends to be negative, and positive evidence cannot be replicated, followed by special pleading by proponents. That is the pattern of a treatment that does not work.

We have seen this pattern with treatments that are now not controversial in their failure – phrenology, radioactive tonics, animal magnetism, and Abram’s dynomyzer (turned out to be a black box with loose non-functioning parts). We see the same pattern with homeopathy, therapeutic touch, energy medicine, and acupuncture.

We also see the same pattern for highly implausible (what some would consider pathological) fringe sciences outside of medicine – ESP research, ghost hunting, free energy, and cryptozoology, for example. There are also non-controversial historical examples, such as N-rays.

Of course, those who have not learned the lessons of history are doomed to repeat it.

Posted in: Science and Medicine

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146 thoughts on “Plausibility in Science-Based Medicine

  1. DevoutCatalyst says:

    Doomed to repeat it often. If Therapeutic Touch is plausible to Katz, what on earth isn’t? In this integrative way of thinking, anyone can create a new alternative therapy with a Ministry of Silly Walks assurance that if it develops some kind of following, it can’t and won’t be dismissed by CAM, ever. You’re in — free and accepted. Gin soaked raisons d’être indeed.

  2. mikerattlesnake says:

    I think it’s a wise addendum to directly address the logical misstep in the question you recieved. Those who understand SBM would get the answer from the broad approach taken in your post, but those people aren’t the ones likely to parrot the fallacy.

    To put it simply: finding that an antibiotic was effective against an ulcer would indicate a bacterial cause for ulcers that would warrant further study. The reason for that has entirely to do with prior plausability. Antibiotics are known to fight bacteria. If an antibiotic cures ulcers, it gives us a plausible answer for the mechanism causing ulcers. The questioner makes the mistake of assuming that we would never abandon the assumed cause of ulcers, but SBM looks for mechanisms of action for ailments as well as cures.

    Good article Steve, I just felt like you didn’t address that directly enough for the folks who would be likely to ask that question.

  3. lizkat says:

    [our models of biology and physiology have made such notions unnecessary, resulting in the discarding of “life energy” as a scientific idea over a century ago.]

    There was no good reason to discard the life energy theory. Your models of biology and physiology are very very far from being comprehensive and complete. When scientists discarded the concept over a century ago, it’s just possible that they were mistaken.

    Since there is, at least, a very large quantity of anecdotal evidence for some kind of unknown biological energy (and some would claim there is also adequate experimental evidence), it does not warrant a rating of highly implausible.

    Has mainstream science made a good effort to detect life energy? Maybe not, since the concept had been discarded. The assumption is that it was discarded for good reasons. But what exactly were those reasons?

    The reasons probably were related mainly to the idea of separating modern science from the superstitious past. Anything that traditional people believed in was suspected of being at odds with modern science.

    So life energy got thrown out the window, with or with good scientific reasons for doing so.

  4. lizkat says:

    should be “with or without good scientific reasons”

  5. weing says:

    All this hypocritical nonsense coming from someone who has discarded the reality of Santa Claus.

  6. superdave says:

    lizkat, the very concept of biological energy doesn’t make sense. The The word energy just doesn’t mean what your explanation implies it means. It is true that we don’t know everything about biology and physics but there is no reason to even think that something akin to what you are describing even might exist.

    Anyways, I think devout Catalyst nailed it. You have to wonder exactly what it would take for ANY CAM modality to be rejected by the alt med crowd.

  7. weing says:

    lizkat,

    Substitute Santa Clause for “life energy” in your comments and questions and ask yourself the same questions.

  8. Scott says:

    Your models of biology and physiology are very very far from being comprehensive and complete.

    But not in a way that leaves room for “life energy”.

    Since there is, at least, a very large quantity of anecdotal evidence for some kind of unknown biological energy

    BS. There are anecdotes that have been claimed to be evidence for “some kind of unknown biological energy,” none of which actually hold up to any scrutiny.

    Has mainstream science made a good effort to detect life energy?

    The answer to this is an unqualified, unequivocal, and emphatic YES. As has been explained to you many times before.

  9. TsuDhoNimh says:

    The recent observation that a subset of chemotherapy patients who were concurrently taking a drug for diabetes had higher than usual survival rates is an example of something odd, yet plausible and testable. They were slicing and dicing the data from the medical records deliberately looking for things that either lowered or increased the survival.

    If several anecdotes were reported where antibiotics appeared to cause long-lasting remissions in gastric ulcers, for which no causative agent had been found, the reasonable scientist could propose any number of ways to verify that it really worked, none of which involves isolating the bacteria or virus.

    The difference between EBM/SBM and “alternative” medicine is that the alties tend to quit after the first couple of case reports, declare victory and open a clinic offering the therapy.

  10. lizkat says:

    weing,

    We have no anecdotal evidence for the current existence of Santa Claus. We know for a fact that Santa Claus, although probably originally based on a real person, is a fictional character. We can trace the history of Santa Claus in detail and see exactly how the fiction originated and evolved.

    The idea of Santa Claus is specific to a certain culture, and has been absent from most of the world’s cultures. There is no sign of Santa Claus in prehistoric cultures, or in traditional contemporary cultures.

    If we see evidence of Santa Claus in different cultures, we can see exactly how the idea was transmitted. We do not see parallel developments of the Santa Claus idea in cultures that have not been in communication.

    Everything that I said about Santa Claus does not apply to life energy. The concept arose in separate cultures and is probably universal. We have anecdotal evidence for its existence, massive quantities of anecdotal evidence.

    There is nothing scientifically implausible about the concept of life energy. Except that it was discarded over a hundred years ago by scientists who were trying to separate modern science from ancient traditional beliefs.

  11. Scott says:

    We have no anecdotal evidence for the current existence of Santa Claus.

    Pray tell, how exactly is the collective experience of five-year-olds finding presents under the Christmas tree, clearly labelled as coming from Santa Claus, NOT such anecdotal evidence? Why, it’s so widespread and consistent that, given the nature of the evidence, it would have to be a culture-wide fraud.

    And if you’re going to hang your hat on specificity to a certain culture, I’m going to have to note the massive collective anecdotal evidence, across MANY cultures, for the existence of a Sun God.

  12. Harriet Hall says:

    “The concept arose in separate cultures and is probably universal. We have anecdotal evidence for its existence, massive quantities of anecdotal evidence.”

    Ditto gods, ghosts, life after death, the significance of dreams. These are evidence for the common psychological makeup of all humans, not for the truth of the beliefs.

  13. qetzal says:

    lizkat:

    We have anecdotal evidence for its [life energy's] existence, massive quantities of anecdotal evidence.

    No, we don’t. We have massive quantites of anecdotal evidence where something appears to have had some effect. You and your fellow proponents then arbitrarily declare that as anecdotal evidence for life energy, ignoring the much more plausible explanations of placebo effects, experimental errors, bias, and the occasional outright fraud. Note that all of the latter are well known to exist, and are more than adequate to explain your “massive quantities of anecdotal evidence.”

  14. If there is nothing scientifically implausible about the concept of life energy, then there is nothing scientifically implausible about Santa Claus either.

    “Life Energy” is not described the same way throughout history and across cultures, and the methods proposed to manipulate it are not the same either. So while Santa Claus is culturally bound, the fact is that stories of magical beings exist everywhere. So he has exactly the same status as Life Energy: a particular name for a universal concept.

    “Scientific” implies the simplest explanation (but no simpler) that explains the data and generates testable hypotheses.

    To the extent that “Life Energy” does not meet these criteria, it’s not scientific. (It’s not the simplest explanation and it doesn’t generate much in the way of testable hypotheses.)

    To the extent that “Life Energy” is testable, it has produced exactly the results expected of an incorrect theory: the best tests don’t support it.

    This is the example my physics teacher in my Christian high school used of a non-scientific (that is, useless) explanation.

    Q: How does a car work?
    A: Angels.
    Q: Doesn’t it have something to do with gas? Cars don’t work when there’s no gas in them.
    A: Angels like gas.
    Q: Cars all have these big engines in them. I’ve never seen a car work without an engine. The engine must have something to do with it.
    A: Angels like to live in engines.
    Q: Really, it seems to be the engine. I put gas in the car, turn the key, and the engine starts to make a lot of noise. Then the car moves.
    A: The noise is the sound of the angels dancing because they are so happy about the gas. Then they move the car.

    Angels are a non-scientific explanation not because angels can’t exist, but because they don’t generate testable hypotheses that will help you fix your car when it stalls. Anything about a car can be “explained” by saying that angels like it that way. But using the angel explanation doesn’t predict what you could do to improve a car or fix it when it’s broken.

    If your defense of “life energy” is that a lot of people throughout history and across cultures have believed it, well — a lot of people throughout history and across cultures have believed a lot of things. A flat earth, for instance. It’s just the easiest explanation to hand. The thing is, most people abandon the useless/superfluous explanation once they a useful one is available to them. So I’m not sure what your point is.

  15. weing says:

    Santa may be known by other names, just like you have prana, chi, life energy. Why are you so quick to dismiss Santa’s existence? You have to do scientific testing.

  16. trrll says:

    Since there is, at least, a very large quantity of anecdotal evidence for some kind of unknown biological energy (and some would claim there is also adequate experimental evidence), it does not warrant a rating of highly implausible.

    So why is “life energy” so implausible that anecdotal claims do not constitute evidence? Here is how a scientist thinks about it:

    1. All known forms of radiant energy are associated with physical waves or particles. Detectors for such forms of energy exist. Biological systems either do not produce such forms of energy, or produce them at levels that have never been found to affect biological systems.

    2. As the body is mater of atomic matter, any hypothetical form of energy that affects the body must interact with matter. Yet nobody has been able to come up with any kind of detector that reliably detects a form of “biological energy” that is not due to known particles and fields. In addition, many different types of physical experiments in which various types of matter are brought together at high energy have identified numerous novel particles, yet none that could plausibly play a role in biological processes. Such experiments have even been successful in detecting massless particles such as the neutrino via careful accounting of energy and momentum. Studies of the chemical reactions of life have also failed to detect any “missing energy” that might be carried away by undetected waves or particles. All known biological processes work via the known and detectable forms of energetic interaction–there is no “gap” waiting to be filled by some additional form of energy.

    3. So we are hypothesizing some kind of energy that is generated by the matter in biological systems, but cannot be generated by the interactions of matter in particle physics studies, that interacts in an important way with the matter of the body, yet does not have any detectable effects on the matter of the many different types of detectors that have been employed to try to detect such emanations from biological systems. Such energy is supposed critical for the function of biological systems, yet does not seem to be required for the function of cells, enzymes, DNA, or any other part of biological systems.

  17. David Gorski says:

    Note that lizkat is in fact pec, who was banned a long time ago and remains banned. The posting IP addresses of lizkat and pec match, as do their trolling styles. That is good enough for me, and trying to evade the ban using a sockpuppet makes the editors even less likely to consider reversing the ban.

    Goodbye, lizkat/pec. The spam filters have been adjusted. You remain banned.

  18. micheleinmichigan says:

    Oy – everyone drink when someone uses the words “evidence” and “energy healing” in the same post.

    Good article Dr. N. The three distinction levels of plausibility clarified it’s relationship with evidence in SBM for me.

  19. Heinleiner says:

    Didn’t we dispense with the vital force theory back when Friedrich Wöhler discovered that he could make urea from inorganic reagents?

    Vital force (a.k.a. life energy) wasn’t disproven a mere 100 years ago, it was disproven over 180 years ago.

  20. micheleinmichigan says:

    Dr. G. “Goodbye, lizkat/pec. The spam filters have been adjusted. You remain banned.”

    Oh, guess I can put away the tequila then.

  21. yeahsurewhatever says:

    The idea of prior probability is really just a codification of the adage “extraordinary claims require extraordinary evidence”.

    Now, it has been argued, incorrectly, that this itself is a double standard: this seems to demand a higher standard of evidence on “alternative” therapies, which is “unfair”. No, that’s not the case.

    In reality, the very fact that these therapies are further away from accepted science just means that more evidence is required to bring them into the fold. More needs to be explained in order to reconcile them with known reality. It’s not a matter of a standard at all — much less a double standard — but rather a simple fact that you have to travel farther to get home if you start out farther from home. It’s a mere logical implication of the extraordinary claim itself.

    Well-meaning, reputable physicians who respect EBM often misunderstand the above. EBM is worthy of respect, especially in historical context; it’s just that it does not go far enough and we can do better.

  22. Dacks says:

    lizkat=pec?! Well, duh. Should have figured that one out. Thanks for saving the ether-inter-energy-net-thing from transmitting hundreds of fruitless words spent debating an incorrigible troll.

  23. Fifi says:

    Dr Hall – “Ditto gods, ghosts, life after death, the significance of dreams. These are evidence for the common psychological makeup of all humans, not for the truth of the beliefs.”

    True but they’re not only evidence of the common psychological makeup of most humans. Many of these common beliefs are based on cognitive glitches or tricks of cognition that most of us seem to share (not everyone in a specific culture will experience these glitches but someone in every culture will – from schizophrenia and hearing disembodied voices, to sleep paralysis and so on). Of course, holy men throughout history have used all kinds of tricks to keep business booming as well – such as creating “miracles” or using magic tricks to give the impression that they have supernatural powers, to using drugs and inducing trance states through other means (once again, this is merely manipulating cognition and neurobiology).

  24. Scott says:

    Aw shucks. I was just getting warmed up for a nice vigorous discussion, too.

  25. cervantes says:

    It’s not a defense of wumeisters whatsoever, don’t get me wrong, but there have been instances in the history of medicine when we’ve gotten stuck on an explanatory model that turned out to be mistaken or there has been collective rejection of a novel idea simply because the claim seemed a bit too extraordinary. Prions, tumor angiogenesis, ulcers as a psychosomatic manifestation of stress, autism as bad mothering, psychodynamic theories of schizophrenia — I could go on and on.

    I expect it’s inevitable, when you build any edifice of knowledge, that it will contain blind corridors that it takes a while to back out of. But sometimes I do feel that our thinking has a tendency to get too conservative and to run a bit in ruts.

    Just a thought.

  26. Geekoid says:

    Great article.

    David – Thanks for your vigilance.

  27. Scott says:

    Prions, tumor angiogenesis, ulcers as a psychosomatic manifestation of stress, autism as bad mothering, psychodynamic theories of schizophrenia

    Please provide evidence that the replacement concept for any of these received less attention than was warranted by the evidence for them at the time. Skepticism about a new idea is completely appropriate regardless of whether it eventually proves to be correct.

  28. BillyJoe says:

    mikerattlesnake

    “To put it simply: finding that an antibiotic was effective against an ulcer would indicate a bacterial cause for ulcers that would warrant further study. The reason for that has entirely to do with prior plausability. Antibiotics are known to fight bacteria. If an antibiotic cures ulcers, it gives us a plausible answer for the mechanism causing ulcers. The questioner makes the mistake of assuming that we would never abandon the assumed cause of ulcers, but SBM looks for mechanisms of action for ailments as well as cures.”

    I like it.
    Only one thing though: this could never have happened. As I understand it, the treatment involves taking three different tablets – two anitbiotics and an acid supressing drug – twice a day for a week. How likely is that to have happened by chance?

  29. micheleinmichigan says:

    Scott – “autism as bad mothering” – did they ever have evidence beyond a correlation between mothers who hugged or talked to (non-responsive) children less and autistic children?

    I think the issue there was that medicine jumped on a theory a bit too quickly rather than respond with appropriate skepticism. That history topic was sort of my beginner’s lesson in what happen when you confuse correlation with causation.

  30. superdave says:

    aww, i liked pec.

  31. David Gorski says:

    David – Thanks for your vigilance.

    Actually, Kim Atwood caught it. I simply verified it. :-)

  32. pmoran says:

    Look, *I* thoroughly “get” the plausibility thing, but it it is not at all clear why some people do and people with similar backgrounds don’t.

    I have expressed doubts previously on this blog as to whether a focus upon the scientific plausibility of the individual CAM claims is a very effective way of countering pseudoscientific medicine. It doesn’t seem to have worked that well so far, or we wouldn’t be here complaining the intrusion of of pseudo-science into academia and elsewhere.

    It seems obvious to me that the Katzes can retain traces of spurious credibility for their “science” by simply needling away at our 99.99 +/-? % scientific certainty. We skeptics are expected to prove everything we say in spades, a difficult task within thousands of words for even one of these modalities, whereas he merely has to keep on pointing to matters that raise minor doubts, especially ones that most people are unable to immediately evaluate and will never bother to, anyway.

    The pseudoscientists are helped along by the fact that most lay people and some doctors are reluctant to completely dismiss the impressive personal testimonials of their friends and the intense self-belief of the seemingly noble practitioners. Where there’s all this smoke, may there be a little fire? And in the end, does it really matter how it works? (Well, yes, but not to the patient and preening practitioners.)

    Thus, pseudo-science bubbles away happily, and we get to grumble on righteously about it, so long as there are people prepared to give it the benefit of the doubt and try it out as either patient or practitioner, and in their turn become convinced that it “works” through various well-known illusions of medical interactions as well as probable placebo reactions.

    I would like to see a different approach tried.

    For example, was Katz asked how far he is from accepting that the clinical benefits he observes from the modalities he supports are from placebo reactions — and that evidence to the contrary is meager? That this provides the only rational and economical explanation for why SO VERY MANY contrasting, almost mutually exclusive medical theories are producing very similar spectra of claimed medical activity and despite now massive practical experience not one single reliable “killer application” ?

    I believe that the emphasis upon one aspect of medical science (the intrinsic efficacy of treatments) by SBM is making its job harder. Too many people just don’t “get” it. They will at best reserve judgment.

    Such an emphasis may be making the job harder in other ways.

    SBM is effectively saying “We will ignore any potential for true patient benefit from these placebo medicines in our dealings with CAM practitioners and the public, in defiance of some highly suggestive scientific evidence concerning placebo and other non-specific elements within medicine. We can then present our case in such a way that only the most humiliating admissions of willful self-delusion from our opponents and their patients will count as a “win” in the ongoing debate. Oh, and we want their total surrender to what is an important, but perhaps not always wholly applicable model of medical practice, one that is itself still in the process of evolving into final form(s). “

  33. Lawrence C. says:

    Thank you for what I think is an excellent article. I appreciate the broader philosophical points as expressed in a science-based medical framework. In particular, it is refreshing to see these airy references to quantum realities that people like this Dr. Katz use dismissed for what they are: a distraction at best and a deliberate conjurer’s trick at worst. After hearing so many such abuses of physics for so long I’m immune to any negative reaction to them. Nevertheless it is a good thing for me to come across a good piece of writing that keeps such abuses in their proper place, which is to say, outside the proper discussion of medical science as it is practiced.

    As a side note, many are probably familiar with the silly college drinking game of ending every sentence with the phrase “in bed.” In a similar manner. one can make many a physicist howl with laughter if you begin or end every sentence with “at the quantum level.” As soon as I hear those words I know that what follows is almost always nonsense and one might as well laugh instead of cry when such things happen.

  34. daedalus2u says:

    YSWE, I think you have the idea of prior plausibility not quite right. An idea does not have low prior plausibility if it does not agree with prior explanations, it has low prior plausibility if it does not agree with prior data.

    Many (most?) scientists make this confusion too. That is because they are thinking on the level of the explanations, not on the level of the data that led to those explanations. The explanations may be wrong, the data that led to them is not.

    The idea of using antibiotics to treat ulcers was incompatible with the idea that ulcers were due to too much acid. It was not incompatible with any of the data surrounding ulcer treatment.

    Correct ideas are never incompatible with the data. If a new explanation is compatible with more data than an old explanation is, then we should adopt the new explanation.

    Dr Novella’s invocation of the ideas of conservation of mass and thermodynamics to put a low prior probability on homeopathy represents the degree of testing to which those ideas have been subjected to and the levels of certainty with which they are held. If conservation of mass and thermodynamics were wrong (and they would have to be for homeopathy to be correct), then we would have to abandon just about everything science has done since 1900 and start over. Abandon millions of person-years of scientific effort so that we can imagine homeopathy is correct? Based on badly done clinical trials?

    All of the great paradigm shifts in science did not contradict the prior data. A heliocentric solar system didn’t contradict any astronomical observations. Relativity didn’t contradict any Newtonian based data, quantum mechanics didn’t contradict any classical physics data. Relativity contradicted the idea of the luminiferous aether and the idea of absolute reference frames in space, it did not contradict any data.

  35. jster says:

    The levels of plausability are certainly very interesting and clearly a cornerstone of medicine. Any epidemiologist knows that there is no need to understand the mechanism of something to be able to intervene if enough data has been collected.

    A historical example of this is the father of epidemiology, John Snow, shutting down the water pump which was causing an outbreak of cholera. He had no idea about this being a bacterial disease never mind being close to identifying Vibro cholerae. A more modern example is the “Back to back” campaign of lying babies down on their backs to sleep. This has been shown to dramatically reduce cases of Sudden Infant Death Syndrome (SIDS) or ‘cot death’ without any definite idea about what causes the condition. If you can find strong evidence you can act without full understanding. The problem for CAM is that they don’t have the evidence or the plausability in many or most cases.

  36. art malernee dvm says:

    can anyone promoting SBM measure scientifically a difference between ebm and sbm in the real world that can be repeated by others? I think that would help me see a difference. What is the difference between plausibility and someones opinion of what happened in the past. When you apply plausibility to a important clinical problem what is scientifically measured?

  37. JMB says:

    @art malernee dvm

    I would offer a discussion for the question you ask. Consider this just a temporary answer, I am just one who makes comments. Just a quick preface, EBM and SBM are methodologies for the practice of medicine, not the design of medical science experiments. There are plenty of areas of agreement between SBM and EBM. An area of disagreement between SBM and EBM would of course be where we would focus our scientific measure. One disagreement between SBM and EBM is over whether certain therapies are worthy for the time and expense of randomized clinical trials. If the assessment of plausibility (by SBM advocates) has some positive predictive power as to whether a RCT experiment might be successful (it would probably be pretty low, but still higher than a shot in the dark), then it could be argued that it is a waste of precious resources to perform an expensive trial on a treatment without a plausible explanation. So instead of spending money on a randomized clinical trial of energy healing, we should spend it on the drug developed by a pharmaceutical company using quantum mechanical/molecular modeling techniques to design an enzyme inhibitor of an enzyme found on the surface of the influenza virus.

    To get more directly at the question you asked (or at least my interpretation of your question), will the advocate of SBM have better outcomes with patients than the advocate of EBM? Well, we could design an experiment to compare the two, but considering the amount of variation in patients, it will be hard to insure that patient variability will not effect the difference in group outcomes without using very large numbers of patients. Now consider the variability in the skills of the doctors, it will be hard to control that variability without large numbers of doctors. Such an experiment would be very expensive, and is unlikely to be funded.

    Let’s take another area of difference between SBM and EBM that we might apply a different kind of measure than a scientific measure. In the practice of medicine we routinely face issues of ethics, so this will be an ethical measure, not a scientific measure. Say we are dealing with a patient dying with metastatic cancer in pain. Their financial resources have been drained by last ditch efforts at extending life. Now EBM articles have discussed the use of CAM techniques in the control of pain of terminal patients. Is it more ethical to suggest to the patient that they spend their last $100 dollars on morphine or acupuncture? (No, I’m not advocating euthanasia with morphine.)

    Now, for my own diversion of the discussion. Would it make more sense for government rationing to be based on SBM or EBM? Well, SBM would probably result in more treatments being funded based on plausibility and limited clinical observation studies. EBM would more likely deny funding of plausible treatments supported by limited clinical observation studies, but allow more treatments based on implausible scientific concepts, but with limited support of larger observational trials. In the end, more money is saved by the EBM approach because energy healing is cheaper than the new pharmaceutical drug. Educating someone to the high school level of understanding of quantum physics is cheaper than using a PhD in quantum physics running a supercomputer for modeling enzyme drug interactions. I guess there is a certain irony there, since woo is cheaper than real science, more studies can be completed, enabling that 5% of sampled results to be judged as statistically significant difference. EBM has reopened the door to quackery. At least most quackery is cheaper.

  38. ebohlman says:

    michele: The “refrigerator mother” theory of autism stuck because it was propounded by Bruno Bettelheim, a charismatic charlatan who just happened to be a Holocaust survivor and therefore enjoyed the Sanctification of Victimhood. There’s this notion that some traumas are so severe that you can’t “invalidate” anyone who’s experienced them (the no-invalidation rule is supposed to be really progressive and based on replacing harsh masculine ways of knowing with kind feminine ways of knowing; in reality, it comes from the group-confessional doctrines of 12-step recovery where the more outrageous the things you claim your addiction made you do, the more you spiritually benefit, so nobody’s supposed to question any of those claims).

    You could legitimately call it the John McCain POW gambit.

    Ironically, Bernard Rimland drove the final stake through the heart of Bettelheim’s “theory” and as a result became such a Hero that he himself was able to get away with spouting nonsense on autism causation. Appeal to authority is one of the harder logical fallacies to resist.

  39. micheleinmichigan says:

    # ebohlmanon 11 Mar 2010 at 6:20 am

    “michele: The “refrigerator mother” theory of autism stuck because it was propounded by Bruno Bettelheim, a charismatic charlatan who just happened to be a Holocaust survivor and therefore enjoyed the Sanctification of Victimhood.”

    Hm, that’s interesting I would have thought that the idea gained traction because it validated a cultural bias that we often engage in. That is parenting has complete control over child behavior (even into adulthood). Similar to the reason that people (not medicine) still seem to want to believe that schizophrenia must be caused by a childhood family trauma.

    I would guess that if Bettelheim had presented an idea that was incompatible with culture bias. Say, that autism was caused by the parents attending church because all of his study subjects’ parents attended church, then he would have had a much harder time gaining traction.

    But it is certainly irrefutable that a charismatic, smart person with a powerful story can take those cultural bias’ that simmer beneath the surface and make them into a movement. It seems to me (from brief reading) that is what Bettleheim did (either knowingly or unknowingly.)

    But, I am musing. I am by no means an expert.

  40. Daedalus – excellent point. I wish I had emphasized that myself. Scientific theories change either in response to new data or in response to new theories to explain existing data. We should not confuse the theory with the data it explains.

    Regarding the “cold mother” and other discarded ideas – two points to emphasize. The first is that in these examples the scientific process eventually corrected the mistakes – that is how you know about them. The only question is, did it take longer than it should have – and this is a complex question.

    Second – when looking back at wrong ideas that are now discarded or ideas that are now accepted that were initially resisted – there is a post-hoc bias. What about all those ideas that were met with skepticism and turned out to be wrong. Sometimes people act as if correct ideas should be recognized immediately, of course they only make that argument after years of science has sorted out which ideas are correct.

  41. cervantes says:

    I’m coming back to this late, but let me try to respond briefly to some comments. The issue with the refrigerator mother theory (it was more than a mere hypothesis) wasn’t just that people jumped on it too quickly and it was sold by a charismatic champion; at the time we still had a basic view of personality development that was largely limited to psychodynamic processes. Schizophrenia and autism were both seen as entirely psychodynamic in origin. (Read “Becoming Psychiatrists” by Donald Light for a real eye-opener!) We still had a fundamentally dualist view in which the mind was somehow other than the brain, so people were not inclined to look to the organ as an explanation for problems of mind. Even the idea that personality traits could be congenital was widely reviled.

    My basic point is simply that yes, ideas outside the prevailing paradigm are going to be viewed skeptically and should be, but we also need to recognize that we often get stuck in paradigms that are too limiting, and even essentially wrong. We need to encourage robust, creative, speculative thinking. That doesn’t mean arbitrarily deciding that some wild idea is right; it does mean being willing to check it out if it seems defensible.

  42. Fifi says:

    It’s worth considering the “refrigerator mother” theory in context – what seems obvious to us now obviously wasn’t obvious at the time. It’s worth noting that it was a theory that was not only about autism but also about schizophrenia, and it was formed at a time when we didn’t have the knowledge about neurobiology and genetics that we now have. (Many of our current theories will probably also look a bit absurd or crude in the light of future knowledge. It wasn’t that long ago that we started to understand neuroplasticity and it’s only because of new technologies/tools that we came to accept and understand it to the point we do today, which isn’t completely by any stretch of the imagination.)
    Certainly cultural (and personal/political) biases have played into all kinds of medical theories – from homosexuality being a “disease” to women being bad at math. (And, yes, neither of these ideas are totally dead since there are people with biases that continue to peddle them even at the upper echelons of science.)
    But back to autism and “refrigerator mothers” – from an observational perspective it’s actually quite understandable how this theory came into being. Since autistic children often don’t bond or like touch, it’s inevitable that mothers without coping tools or a great deal of patience and unconditional love will withdraw affection and express frustration. A lot of mothers have expectations of their child that an autistic child thwarts. Throw in the possibility that mothers or fathers of autistic children may have some autistic tendencies themselves, which would make them less prone to express physical affection, and one can see how it might appear that there’s a link between how a mother acts “cold” or “distant” and how a child develops. Of course, there IS a link between how a mother acts and child development – even in regards to autism. “Cold” (meaning emotionally withholding and/or cruel, authoritarian or negligent) primary caregivers do generally have a negative impact on child development (particularly if there’s no compensating supportive caregiver or presence in a child’s life). There’s a reason why we consider child abuse to be child abuse!
    Autistic children do tend to do better with patient, nurturing caregivers than they do with rigid and authoritarian ones that withhold affection or express anger and frustration that their child isn’t responding how they’d like. While the “refrigerator mother” theory has cause and effect wrong, how a caregiver of an autistic child treats that child will still have a developmental influence.
    It’s worth remembering that Bettelheim wasn’t alone in holding some ideas that now seem quite absurd but were very much accepted by the medical establishment at the time. And, while Bettelheim was off the mark regarding the causes of autism (and like many famous doctors sounds like he was suffering from grandiosity and potentially a NPD), he wasn’t totally off the mark regarding bonding, affection and child development. It’s also worth noting that quite a bit of pressure that led to a change in ideas came from parents advocating for their children and not directly from science, though it took a scientist speaking up and presenting an alternate theory for them to be taken seriously by scientists (the same is true of how our ideas about homosexuality changed).

    We seem to expect that if someone is right or wrong about one big idea that they’re either right or wrong about everything. The reality is that a lot of the time – particularly when we don’t have the tools to actually gather entirely objective data – we’re groping around in the dark trying to figure out why something is what it is. The reality is that, even for autism, we’ve got an incomplete picture of the causes of all kinds of mental disorders (which is, of course, why it’s easy for people to use/sell woo to fill in the gaps…it’s the usual god of the gaps effect). This is, of course, complicated by cultural beliefs and biases about what is mentally healthy and what isn’t and so on.

  43. Fifi says:

    cervantes – “Even the idea that personality traits could be congenital was widely reviled.”

    And it still is by many lay people. One reason is that it gives rise to the spectre of eugenics because we attach so many value judgments to personality traits (based on social or cultural biases….different but equal seems to be hard for a lot of people to grasp, there are still quite a lot of people that cling to the idea that equal requires sameness). The other reason why the idea that personality traits can be congenital is reviled is that it confronts our ideas about how much control we have over who we are and our actions. (Meaning it confronts our self identity and the narratives we construct about who we are and how we became who we are.)

    The other problem is that there’s still a popular nature vs nurture belief even though science is increasingly proving it’s both nature AND nurture. Personality traits may be congenital but they can be changed by changes in neurobiology (due to medications, learning or brain damage or disease). And, on an even larger scale, these questions can have a very profound bearing on our social conventions regarding justice, responsibility and fairness.

  44. Fifi says:

    It’s also worth noting that there’s a difference between children that were diagnosed with autism at that time and the children that are diagnosed with autism now. The very concept or diagnosis of autism was quite different in the 50s than it is now (and even more different prior to that since it included schizophrenia). Many children who are now diagnosed with more extreme forms of autism now would have simply been considered intellectually handicapped and imbeciles once upon a time (that’s why there appears to be an increase in cases of autism, our diagnostic criteria changed). So, may of the things that seem very obvious to us now are due to the work of people who got a lot of things wrong but some things right…enough right to get us to where we are now at least…which is still far from having a complete understanding. Considering the tools available – which were basically observation – these pioneers did pretty remarkable work.

  45. Cervantes,

    What is your evidence that scientists remained stuck in psychodynamic theories of schizophrenia and autism at a time when they had good alternatives? ECT, psychosurgery and insulin coma were both used to treat schizophrenia until the 1950s when Thorazine became available — and used.

    This suggests to me that the organic nature of mental illnesses was very well accepted. If clinical research continued to explore less invasive treatments (as it continues today), do you have a good reason to assert that this is because clinicians believed the physical brain could not be ill or abnormal, and not because the risk/benefit ratios of the available treatments were often too high?

    michele,

    The mother/ psychodynamic theories of autism and mental illness were part of a a time of hope. They were popular even though they were not necessarily the primary focus of scientific research.

    If children were blank slates then we could reject the values of the society that created war, racism and holocaust; that constrained people to robotic paradigms, robbing them of their creativity; and that made them autistic and mentally ill. Instead, we could embrace new values of love and liberation that would free us to create a new world without race, sex or class populated by our loving, nonviolent children. Creating this new society could be as simple as loving your children well, allowing them to express themselves, and isolating them from pernicious outside influences.

    There was a lot of pressure on mothers.

    My mother started parenting in 1964 and her youngest turned 21 in 2005. She loves the new genetic paradigm, where kids just are who they are and the job of parents is just are to raise and educate them as best they can. If the child grows up to be mentally ill, then instead of being blamed for creating the mental illness the parent can be admired for their strength. It’s great!

    But I guess today the job of the parent is also to recognize everythng that the child has that might be disordered and to arrange an appropriate treatment. That approach has its own burdens and risks, but unfortunately they don’t come with the promise of a world without war.

  46. mikerattlesnake says:

    to (briefly and unnecessarily) return to “life energy”:

    Here’s a great scientific test for life energy, the assumption being that it exists in all living things, is the essence of their life/healing, and can be manipulated by certain professionals.

    First, take some of those “almost cells” created in early earth replication experiments (this is probably a terrible way to put this, I am feeling lazy about specifics at the moment), put them right next to or on a person (or other living thing), and have the manipulator just push some of the life energy into them. Sure, it would NEVER work with a table or other inorganic objects (that would just be SILLY), but if these things are close to primitive cells, we should see some characteristics of life emerge when they are filled with life energy.

    Cue, “but it doesn’t work that way!”

  47. mikerattlesnake says:

    ok, that might be a terrible test, but substitute “recently dead bacteria” or anything else that is close to being a living cell and it holds up and would be just as impossible.

  48. Fifi says:

    It’s also worth remembering that there were and still are many competing theories and different schools of thought about child development, even within contemporary psychiatry and psychology. Also, the very notion of childhood as we tend to conceive of it now was actually invented in the Victorian era (and the idea of “teenagers” is even more novel).

  49. Fifi says:

    It’s also not surprising that the focus on mothers came at a time when motherhood was becoming something quite different – the 50s housewife is a bit unusual in history. Before this time most affluent women had other people to look after their children and most poorer women also worked. It was only with the rise of the middle class and “homemaking” as a profession in the 1950s American sense that motherhood and mothering became a sort of profession in this way. (Being a nanny wasn’t the same thing at all, and while women ran households prior to the 50s the more affluent ones usually didn’t actually care for their children, they had servants to do this. Poorer mothers did look after their children but they were considered working/contributing members of the household if they weren’t actually sent out to work.) It can be easy to forget just how different other times were when we look back.

  50. Fifi,

    Yes, and beyond child development — even schizophrenia, which is firmly settled in the organic-disease model, has room for a lot of psychological intervention.

  51. micheleinmichigan says:

    Regarding discarded scientific ideas, my intention when looking at such an idea is not to discredit science or claim “look, you can’t count on any theory, science has been wrong before.”

    My BIL (who taught me to ski) says. “You ain’t learning, if you ain’t falling.” So, when I see a discarded idea, particularly one that may have done physical or emotional harm, my reflex is to look at why that “mistake” came about. If it is possible (within the context of the time and their knowledge base) it could have been prevented, mitigated or corrected more quickly with a different attitude or approach. What were the societal pressures at that time, etc.

    It is an intriguing endeavor.

    Once you have done that, a knowledgeable person has a good lens to look at current ideas, theories, treatment with the knowledge that some of them may be incorrect. Sometimes you can use your critique of the past to mitigate or prevent future harm, when possible.

    I know this is not a foreign concept to medicine and it is done often, but it is still interesting and helpful for me.

  52. Fifi says:

    michele – I don’t think acknowledging how ideas evolve in medicine and the cultural biases that have informed them is in any way a slight against science – it’s being realistic about our human limitations and the limitations of the tools available to us at certain points in history. The scientific method, along with our knowledge, has also evolved over time. Knowing the history of ideas and how previous cultural biases can be very useful to prevent making the same kinds of mistakes we’ve made historically (or at least trying to prevent them). It’s one reason why I think it’s important not to get carried away with whatever is trendy at the moment (and, yes, fads happen in science too) in areas where we still have a lot to understand. Those who don’t understand history are doomed to repeat it! :-)

  53. micheleinmichigan says:

    “My mother started parenting in 1964 and her youngest turned 21 in 2005. She loves the new genetic paradigm, where kids just are who they are and the job of parents is just are to raise and educate them as best they can. If the child grows up to be mentally ill, then instead of being blamed for creating the mental illness the parent can be admired for their strength. It’s great!”

    That’s interesting your mom and my mom almost overlapped – my oldest brother was born in 56 the youngest in 65. If I were to characterize how I was brought up then with the attitudes of today’s parenting literature it would be loving neglect. (I have no idea what my mom would have made of the attachment parenting movement. :) We basically wandered free in a gang unless we were in school and sure, my mom bought books. But she did not read them to me every day.

    Today, I feel constantly bombarded with enrichment requirements and suggestions of all the things that could “hurt” my child. There are, toxins, predators, tv, not reading to them enough, not listening enough, not talking enough, eating to much, not eating WITH them enough, not sanitizing, to much sanitizing, homework yes or no, praising yes or no, etc, ad nauseum.

    So I would say that there is still a portion of society who will search out any tiny bit of scientificish data that they can use to sell their idea that parents control how children turn out. AND you should give them money to find out how.

    That said, those activities are primarily in the realm of typical developing children. In terms of children with developmental delays or other issues medicine is much more concentrated on organic (rather than social/parenting) explanations (thank god).

    True, there are many recommendation for techniques or therapies that parents need to engage in to help a child with a delay or disability, but (as your mom suggests) that is a whole different kettle of fish than being blamed for the delay or disability.

  54. daedalus2u says:

    There was some data to support the refrigerator mother idea (not a hypothesis because it was shown to be wrong).

    There was Harlow’s work with monkeys isolated from their mother at birth. Those monkeys exhibited traits called “autistic” by the researchers including self-mutilation, rocking, profound social incompetence, profound vulnerability to bullying and improved non-social cognition.

    Children in orphanages, exhibit increased autism symptoms in relation to how severely they have been neglected. Blaming mothers is real easy. Essentially every new mother is hypervigilant regarding her mothering and is willing to do just about anything to help her infant.

    There is lots of social feedback between infants and mothers, and this is disrupted to some extent in autism. Which is cause and which is effect is not trivially easy to sort out. Autism is notoriously sensitive to placebos. Parents of children with autism are notoriously sensitive to their children being given placebos. Sorting out real change from hoped for change is extremely difficult in autism.

    I don’t doubt that increasing social interaction with autistic children would produce improvement, and that this improvement would have been seen as vindication of the refrigerator mother idea. It also feeds into the mutually reinforcing social dynamics of quacks and curebies. Increased social interaction is analogous to ABA which is the only semi-recognized treatment for autism, but even that has not been subjected to very much well done testing.

  55. Fifi says:

    Daedelus – “Blaming mothers is real easy. Essentially every new mother is hypervigilant regarding her mothering and is willing to do just about anything to help her infant.”

    We can discuss what is constructive and destructive mothering/fathering/primary caregiving without blaming mothers. Most parents are just doing the best they can with what they’ve learned and the knowledge at hand (which is why abusive parenting tends to be handed down from one generation to another, someone’s best may end up being pretty destructive). Not all mother’s are ‘hyper-vigilant” and, generally speaking, that’s not actually that healthy a mother-child relationship (and can contribute to children growing up to be very anxious adults). We see a lot of this kind hyper-vigilant or “helicopter” parenting where parents don’t allow their children to develop normal autonomy and even motor skills because the parent is so terrified that their child will get hurt they don’t let them play and develop at a normal rate. The ideal mother is often referred to as the “good enough mother”, meaning she’s present and attentive when needed but also able to let her child explore and develop autonomy. She models healthy behavior for her children, while the hyper-vigilant parent models unhealthy and fearful behavior.

    daedelus – “I don’t doubt that increasing social interaction with autistic children would produce improvement, and that this improvement would have been seen as vindication of the refrigerator mother idea.”

    It’s not necessarily increased social interaction, it’s the quality of interaction. Increased destructive interaction would only serve to acerbate the problems. In the “refrigerator mother” model (and it was applied to father’s too) they may actually give their child attention, just not patient, affectionate attention that actually deals with the child as they are and on their level.

  56. Fifi says:

    michele – Sounds like you benefited from having a “good enough mother” :-) And, yes, some contemporary parents seem to have a very strange fetishistic relationship to their children (narcissistic even, where they see them as object that reflect back on the identity/image of the parent rather than beings in their own right and with their own personalities). Not that this wasn’t the case with some parents historically as well, it just seems to be much more widespread these days.

    Parenting does make a difference, particularly in the very early developmental stages since we’re mammals and finish our gestation outside of the womb. It takes a couple of years for us to be ready for benign neglect, pretty much until we can start asking for what we want or get it ourselves.

  57. Fifi says:

    michele – “In terms of children with developmental delays or other issues medicine is much more concentrated on organic (rather than social/parenting) explanations (thank god).”

    I’m not sure this is true really, it’s well recognized that abusing or neglecting young children causes developmental delays (nature and nurture here, where the nurture or lack thereof influences neurobiology and whether necessary developments happen). Just as it’s well recognized that some developmental delays (or total lack of development) are due to either problems during pregnancy that cause a child to be born with neurobiological issues or are a result of inherited genetic traits. Due to the nature of brains, there’s plenty of room for both nature and nurture and it’s about discerning the accurate cause and effect relationship not simply preferring one over the other for ideological or emotional reasons.

  58. micheleinmichigan says:

    To be clear, (just in case BillyJoe’s science on the existence of an after life is wrong), I had a kick ass, awesome mom. I only wanted to state that by today’s parenting magazine and Library parenting section standards, her methods would have been considered loving neglect. As I recall, at the time, she may have been considered slightly over protective.

    I have no idea what the parenting lit was like at that time, but I’m pretty sure if you wanted to follow all of the parenting advice now that claims to be based on science, you would have to do it on the quantum level.

  59. micheleinmichigan says:

    “I’m not sure this is true really, it’s well recognized that abusing or neglecting young children causes developmental delays (nature and nurture here, where the nurture or lack thereof influences neurobiology and whether necessary developments happen).”

    What percentage of delays in the U.S. would you say are caused by abuse or neglect? What percentage are organic (not caused by abuse or neglect). Unless you think that the percentage of abuse and neglect is over say 30%, I do not understand how you could disagree with the term “much more concentrated on organic causes” I would call 70% much more than 30%.

    I would guess that 30% is an over estimate. But anyone who would like to present stats on it is welcome to do so.

  60. micheleinmichigan says:

    “It’s not necessarily increased social interaction, it’s the quality of interaction. Increased destructive interaction would only serve to acerbate the problems. In the “refrigerator mother” model (and it was applied to father’s too) they may actually give their child attention, just not patient, affectionate attention that actually deals with the child as they are and on their level.”

    This statement does not sound like any of the more accepted forms of therapy for autism such as Floortime or ABA. Can you provide a reference for the intervention you are referring to and data on it’s success rate?

  61. micheleinmichigan says:

    Just to clarify a couple points in the Autism causation thread.

    First time line (from Wiki)
    1949 – Kanner suggested autism may be related to a “genuine lack of maternal warmth”
    1950-1970 – The period of time usual stated for the Refrigerator mother idea was.
    1957-1963 – The Harlow rhesus monkeys experiments were conducted from . So while they may have reinforced the “Refrigerator Mother” misconception, the ideas were not based on these experiments.
    1989+ Romanian Orphanage Studies

    Second – the Difference between Institutional Autism and Organic Autism.

    Cases of Institutional Autism have only come into prevalence since 1989 with the Romanian Orphanage studies, But there were smaller observations (not studies) of autism like symptoms caused by institutional care before that.

    I will quote from an excellent article on Institutional Autism by the Boris Gindis from the Center for Congitive-Developmental Assessment and Remediation, New York. For folks interested in the topic, I highly recommend the article. It also has a list of sources at the end for further reading.

    http://74.125.95.132/search?q=cache:mKWcGmtqi_kJ:www.internationalsped.com/documents/Gindis%2520Institutional%2520Autism.doc+institutional+autism&cd=6&hl=en&ct=clnk&gl=us&client=firefox-a

    “Historically, the notion of institutional autism can be traced to an article by British/American psychiatrist Rene Spitz (1945). Spitz described several patterns of behavior he observed in young children who had been placed in the London Children’s Hospital after their parents perished during the Nazi bombardment of London in 1940-1942. In reaction to emotional traumata, loss of primary caregiver, isolation in hospital cribs, and lack of stimulation, these children developed symptoms that were at least similar to those often found in children with autism.”

    Note: Institutional Autism is a distinct disorder separate from Organic Autism.

    “A differential diagnosis between autism as a medical condition and learned autistic-like post-institutional behaviors is to be made. A conclusion is drawn that institutional autism is merely a description of certain patterns of post-institutionalized behavior that may appear similar to what is observed in children with autism. ”

    Why is the differential important?

    “The notion of institutional autism is confusing for personnel involved in remedial work with post-institutionalized children because if a child has autism, a range of proper educational (remedial methodology) and administrative (placement and services) actions should take place. If a child demonstrates institutional behavior, a completely different set of actions should take place. ”

    I must point out that none of the institutional conditions studied are applicable to the “Refridgerator Mother” misconception. These are conditions of extreme privation at levels not documented in these mothers. There is a huge difference between a Romanian orphanage and “a genuine lack of maternal warmth” (read – lack of therapeutic training in parenting a child with autism.)

    The article concludes – “Now that the biological nature of autism is well documented (Trottier, Srivastava, Walker, 1999; Freitag, 2007), suggesting that social factors (e.g.: deep institutional privation Rutter, 1999) without known neurological aberration (or other biological and genetic causes) can result in autism (even with modifiers such as institutional) seems a relic of psychogenic theories of the causes and origins of autism. It is a scientific fact that no known psychological factors in a child’s development have been shown to cause autism, and autism spectrum disorders are certainly not caused by bad parenting or rearing in an institution. ”

    I thought it important to take the time to clarify this. In the general population (outside the international adoption community) I have found that people generally confuse the two diagnoses. Also, I know a number of parents of child with autism frequent SBM, so it is important that the organic nature of Autism be clarified.

  62. Fifi says:

    michele – With all due respect to your personal experience and good intentions, I’d suggest that you may be sensitive regarding this issue and reading more into what I wrote than is there because you have a horse in this race yourself. I certainly wasn’t questioning the organic nature of autism, I was merely pointing out that parenting (or lack of parenting) effects neurobiology too. I’m talking about nature AND nurture and how they interact.

    This isn’t blaming parents or caregivers, it’s merely recognizing that, like other mammals that finish their gestation outside of the womb, that our early neurobiological development is influenced by caregiving (or neglect). One reason why we’re looking for ways to diagnose autism at an early age is that early intervention, when neuroplasticity is at its peak, is more effective. One reason we take away infants from abusive parents is to prevent further neurobiological and psychological damage.

    Unfortunately child abuse and neglect happens in both obvious and less obvious ways, and in both wealthy and impoverished countries (and homes and institutions). Recognizing that child abuse and neglect causes neurobiological and psychological damage isn’t negating organic autism in any way. And recognizing that there are constructive and destructive methods of parenting autistic children isn’t blaming the parents. It’s merely looking at cause and effect, it’s not a personal thing or blame thing, it’s just looking at how brains develop and how we can influence neurobiological development…how nurture influences nature (both inside and outside of the womb).

  63. micheleinmichigan says:

    I will quote again, – “It is a scientific fact that no known psychological factors in a child’s development have been shown to cause autism, and autism spectrum disorders are certainly not caused by bad parenting or rearing in an institution. ”

    You either agree or disagree. If you disagree, I’d be interested in seeing the source that you base that on.

    If you agree, I have no dispute, “horse in this race” or not. I’m not sure why you would be concerned with how “sensitive” I am when I attempt to inform readers on some history and the differential between institutional autism and organic autism. This is largely a response to daedalus2u informative comment. Isn’t that something that folks might be interested in?

    If you are not interested. You are free to not read it. But I think observations on my “sensitivity and good intentions” are, well strange. I’m sure the editors can tell me if they are concerned about bandwidth issues.

    Of course early intervention is important. That is one reason I included the quote on differing treatment recommendations for IA vs OA

    Also, no one is disputing that abuse is bad. I don’t know where that is coming from.

  64. Fifi,

    “One reason why we’re looking for ways to diagnose autism at an early age is that early intervention, when neuroplasticity is at its peak, is more effective.”

    Interesting. I was not aware that there was any proven intervention for autism, and I was not aware that it was proven that intervening early was better.

    I know that there are a lot of advocates for behavioural interventions (ABA most loudly) but I also know that the most scrupulous science-based researchers are not convinced.

  65. Fifi says:

    Michele – I never said that parental behavior causes autism, though it seems to me that you’ve been reacting to what I’ve written about the influence of nurturing and neglect on neurobiological development of infants as if I had and with hostility. Perhaps I’m misreading you and you don’t intend to be hostile or to propose that I’m claiming parental behavior causes autism, it’s entirely possible.

    This is what made it seem to me like you are dismissive of the impact of child abuse and neglect. It seemed odd that you’d make this claim about medicine when there’s a lot of research that goes into the social/parenting aspects of development. It also seemed like a double standard to make a guesstimate then demand others present proof. Perhaps we’re simply misunderstanding each other so I’m explaining how I got the impression I did from what you’ve written and why I’ve gotten the impression I have.

    michele – “In terms of children with developmental delays or other issues medicine is much more concentrated on organic (rather than social/parenting) explanations (thank god).”

    Michele – “What percentage of delays in the U.S. would you say are caused by abuse or neglect? What percentage are organic (not caused by abuse or neglect). Unless you think that the percentage of abuse and neglect is over say 30%, I do not understand how you could disagree with the term “much more concentrated on organic causes” I would call 70% much more than 30%.

    I would guess that 30% is an over estimate. But anyone who would like to present stats on it is welcome to do so.”

    We still don’t know the exact causes of autism (though we’ve ruled out “refrigerator mothers”) and it may take us quite a bit more research to do so. We also haven’t entirely ruled out “nurture” (in the sense that an event while in the womb, saying getting the flu, may trigger the genetic expression of autism…nurture isn’t just what happens after birth). However, nurture doesn’t negate the organic nor nature (nor does it blame the individual), it’s part of nature and it’s certainly part of the developmental process of mammals that have young that finish gestation outside the womb like humans. Even if autism has a purely genetic cause that nurture plays no part in triggering, that doesn’t mean that nurture and parental behavior has no influence once a child is born. The reality is that everything is nature, including nurture, and nurture plays a very important role in mammalian infant development.

    I’m not sure where your comments about “bandwidth” come from or what you even mean by them.

  66. Fifi says:

    Alison – “Interesting. I was not aware that there was any proven intervention for autism, and I was not aware that it was proven that intervening early was better.”

    I’m certainly no expert on autism – my experience is limited to working with autistic kids as a volunteer when much younger, having friends with autistic kids and knowing some people who are very high functioning autistic. My impression that early intervention is important comes from a variety of sources, mainly from discussing it with professionals that provide services for autism here in Quebec (we have high rates of autism in Quebec and one of the problems parents face is getting their kids into programs at an early age). Autism Treatment Services of Canada also promotes this idea as being evidence based (though I’d guess they’d have a bias towards treatments being effective, it seems as if it’s commonly accepted by professionals that it is – I am open to being shown otherwise of course! :-)

    http://www.autism.ca/interv.htm

    “There is a wealth of research to support the notion that autistic children experience more gains when treatment is provided to them at an early age. Some research indicates that the early years are crucial for developing language and social behaviour in autistic children. The learning curve of the autistic preschooler is not like that of the typical preschooler. Rather, autistic children often require repeated instruction and practice before a specific skill becomes an ingrained part of their repertoire.”

  67. Fifi,

    You might be interested in the work of Michelle Dawson, a researcher at the U of M.
    http://autismcrisis.blogspot.com/search?q=preschool

  68. micheleinmichigan says:

    FiFi – you disputed my statement “In terms of children with developmental delays or other issues medicine is much more concentrated on organic (rather than social/parenting) explanations (thank god).”

    I clarified that I did in fact mean “much more” not “entirely” as you seem to be reading. Beyond that I don’t know what to tell you. You seem to be reading alot into my posts. Is it hostile to ask for data or a source, when I’d like to see them? You are free not to post them if it is inconvenient.

    Like I said, my post IA vs OA have largely been in response to other posters comments on the history of “Refriderator Mothers”, cultures, etc. I posted some information I found relevant, interesting and might be helpful to some.

    As to bandwidth. I guess I am showing my old time web development days. I meant, if I am taking up too much server space with my long post, I’m sure one of the editors will tell me to cut it out. (At least I said editor, not webmaster. :)

  69. micheleinmichigan says:

    Alison – regarding early intervention. I would like to ramble on about the benefits of a good early intervention service. But now I have to clean house before my son’s TOD teacher (for speech and hearing impaired preschool) stops by for her bi-monthly home visit.

    She is great at training parents in speech and literacy issues. :)

    Maybe I’ll have my ramble tomorrow.

  70. Fifi says:

    Thanks Alison – I appreciate the link and the questions it raises about neurodiversity and “normal” development – that’s a very interesting conversation in and of itself :-) What is “normal”? Is it the same as “healthy”? Or even functional? What does functional mean? Does it mean conforming to social expectations? Or is it about society shifting to accommodate neurodiversity? Interesting stuff to discuss and think about, if hard to nail down in any real way!

    michele – We both seem to be reading a lot into each others posts, or at least feel that the other does – that’s why I am trying to clarify what I meant and what you meant. It’s not hostile to ask for data or a source in and of itself, it’s just seems weird to me to do it while you’re busy guessing and making assertions without presenting evidence yourself. That seems like a double standard to me and contributed to my reading your response as being hostile and dismissive of the role of nurture.

  71. Fifi says:

    michele – Also, since you added “(thank god)” it indicated to me that you probably hold a bias towards a certain belief and bias against the idea that nurture plays a role in child development. (And that perhaps you feel that recognizing the role nurture plays is tantamount to blaming the caregiver. Understanding causation doesn’t necessitate blaming anyone.) I’m open to both possibilities and it seems to me that both nature and nurture contribute to neurobiological development, and from what I’ve seen and read medicine is studying both (as well as how they interact).

  72. micheleinmichigan says:

    FiFi – that whole paragraph for two words “(thank god)”? I merely meant that I am thankful that they have dropped the “Refrigerator Mother” causation idea along with many outdated ideas on parenting and schizophrenia. This was in response to Alison’s post.

    Regarding abuse data. I wish that I could present data. I hate having to guess. That is why I guessed high. Abuse data is notoriously difficult to find and I do not have time to search. If someone has it available I would be interested in seeing it.

  73. Fifi says:

    michele – “FiFi – that whole paragraph for two words “(thank god)”?”

    Um, this is the kind of comment I’m finding hostile and somewhat supercilious.

    Actually, my point was that you didn’t present data for your own assertions about medicine focusing only on organic causes of developmental disorders and made generalizations yet seemed to hold a double standard when I questioned your non-evidence based assertions (because I’ve seen a lot of research into the role of nurture in neurobiological development). Maybe you were only making a throwaway comment or only meant to discuss autism and not all developmental disorders – fair enough – but that’s not what you actually wrote or made assertions about!

  74. Fifi on nurture:
    “you probably hold a bias towards a certain belief and bias against the idea that nurture plays a role in child development.”

    Fifi, what evidence do you have that it is common for people to believe that nurture plays no role in child development? My subjective impression is that while it’s common for abusive parents to conceive of children — even infants — as fully-formed, autonomous individuals who deliberately annoy their caregivers, almost everyone else either explicitly believes that nurture plays a role (even if only a permissive one) in child development or behaves as if they do.

    Given my subjective impression, it would take quite a lot — not just subtle hints — to convince me that someone who presented themselves as an involved parent secretly believed that their parenting could have no effect on their child’s development.

    The fact that you seem to be very open to the idea that someone might believe that parenting can have no effect on child development suggests to me that your information about common beliefs about child development is quite different from mine.

    Care to share?

  75. Fifi says:

    Alison – In the quote you’ve pulled, I was actually referring to the fact that michele seemed to be expressing a bias towards purely organic explanations for all developmental disorders (whether she intended it to come across that way or not), not that it’s common for all people to hold the belief that nurture holds no place in child development.

  76. Fifi says:

    Alison – While abusive parents may blame their children for “making” them punish them, they obviously think their actions as parents have power to influence their child’s behavior. From what I’ve observed, a lot of people pick and choose what they attribute to nature and nurture, and what they do and don’t have power over in regards their children. A lot of people do the same thing regarding their own personalities and actions. And, yes, obviously most parents do think their actions as parents have an effect on their children (but a lot also reject how some of their actions may influence their children’s development). Some people see their children as individuals and treat them as such, some see their children as objects and extensions of themselves and treat them as accessories to their identity. I’ve seen plenty of parents pick and choose what they take credit for and what they attribute to forces outside of their control, it rarely actually has much to do with the science around child development and neurobiology (which is not surprising considering how emotionally engaged most people are with their children).

  77. Fifi,

    If you don’t think it’s a common belief, why is it so easy for you to conclude a particular person holds that belief? I’m trying to understand where you’re coming from.

    I’m asking because there are various themes that you keep hammering on as if you believe they are news. The idea that people’s brains can adapt, for instance, or that abuse is harmful to children. I can understand that you care about these ideas and that you want to share them, but in the context your presentation can sometimes be hard to understand. A little bit as if you were on this forum repeatedly insisting at length that vaccination reduces the risk of contracting illness — and not just in response to Lizkat/pec, but in response, say, to David Gorski.

    Yes, the quote I pulled was your response to Michele saying how glad she was that current research was less focussed on poor mothering as being the cause of “developmental delays and other issues.” Given that I am not in the field, when I think of “developmental delays” my mind quickly runs to things like Down syndrome and autism and then stops. So her statement seems completely uncontroversial to me.

    You replied to this apparently uncontroversial statement by suggesting that she preferred to think that nurture plays no role in child development, a logical leap that I find difficult to follow.

    Michele was not talking about whether parenting and education can have an effect on outcomes for children with “developmental delays and other issues.” She was talking about whether parenting causes them, and whether most current scientific research is predicated on the assumption that it does.

    Yes, there are syndromes related to child abuse that can be included in the category of “developmental delays and other issues,” so yes, it’s more complicated than my initial conception, and thank you for making that explicit.

    Maybe what is making this exchange so confusing to me is my lack of detailed knowledge. Perhaps we lack a shared vocabulary. What “developmental delays and other issues” are caused by poor parenting? Is most research into the causes of “developmental delays and other issues” today really focussed on poor parenting? I had a casual impression that given our fancy new genetic analysis and neuroimaging tools, that most of today’s research was focussed on organic causes and correlates. I would be intrigued to discover I was wrong, because that’s not what the popular press reflects.

    It would be helpful if you shared information that other people don’t have access to (as daedalus and Michele both helpfully did). I suspect most of us accept at a high level, as you do, a role for both nature and nurture in almost every aspect of our physical bodies, including our brains. If you are going to challenge statements, it might go over better if you discussed the issues at a detailed level rather than suggesting that we do not share your high-level understanding.

  78. micheleinmichigan says:

    If I believed that nurture played no role in child development, why would I quote extensively from an article about institutional autism? Which is caused by deficits in nurture?

    If I believed that it was impossible for an abusive environment to played a role in child development, why would I clearly allow that a guesstimate (I just don’t have the stats) of 30% developmental delays could be caused by abuse. I think that stat is clearly too high, but I’m not willing to go on a Google U excursion at this point.

    In regard to my statement once again ““In terms of children with developmental delays or other issues medicine is much more concentrated on organic (rather than social/parenting) explanations (thank god).”

    I will clarify that I was talking about causation. I have no disagreement that various OT, SP, or PT therapies (used by therapist or families) which may be effective in dealing with developmental delays. The therapies, applications and success rates vary wildly depending upon specific conditions. That was not the discussion I was having. I was talking about causation. (She shouts to the oblivious heavens)

    I based that only on my personal experience dealing with a variety of pediatricians and pediatric specialists, a developmental neuro-psychologist, a social worker, a pediatric geneticist, six speech pathologists, two nurse practitioners and a partridge in a pear tree. That is all.

    The article I linked above also has references to studies that state the organic nature of…organic autism. If you want a source, it might be useful. http://74.125.95.132/search?q=cache:mKWcGmtqi_kJ:www.internationalsped.com/documents/Gindis%2520Institutional%2520Autism.doc+institutional+autism&cd=6&hl=en&ct=clnk&gl=us&client=firefox-a

    Here is one of the sources used in the article. Etiology of infantile autism: a review of recent advances in genetic and neurobiological research. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1188990/

    michele – “FiFi – that whole paragraph for two words “(thank god)”?”

    “Um, this is the kind of comment I’m finding hostile and somewhat supercilious. ”

    Yes, now that you have repeatedly mis-characterized my statements several time AND made me spell “developmental neuro-psychologist”, I am feeling peeved. For me that was a impatient remark. Perhaps in Quebec it reads as hostile. In Detroit it reads as mildly peeved. Oh, the wonders of culture.

  79. yeahsurewhatever says:

    daedalus, you’ve flown too high again.

    Correct ideas are never incompatible with the data.

    This is very obviously not true, as there is no such thing as a perfect, infallible vector of data. One has to decide to what extent collected data is reliable, which is a process that cannot be reduced to mathematical formality.

    Correct ideas can be incompatible with data, and incorrect ideas can be compatible with it. What a wonderful world we’d live in if you were right, though.

    Also, I’ll be charitable and assume that by “correct” you mean “provisionally adequate”. There’s no such thing as scientific correctness, for the reason that failing to reject the null hypothesis is not tantamount to accepting the null hypothesis.

  80. daedalus2u says:

    No YSWE, by “correct” I meant actually corresponds to reality. It is something we can never be sure about, because we can never test the correct idea against all cases. But if we did have an absolutely correct idea and we did test it against all cases, it would correspond with the data each and every time (within measurement error). But measurement error is not a problem with the correct idea, it is a problem with the methods we use to test it.

    If data does not agree with the idea you are using, usually the problem is with the idea and not with the data. One has to be very careful to be intellectually honest in looking for problems in data and to not stop simply because one has gotten close to what one feels is the correct answer. Feynman discusses that that in his talks on Cargo Cult Science.

    There is a great deal of science done by Cargo Cult Scientists. Some of it is good. My experience is that the data is often better than the explanation. One of the things that gives me great satisfaction is having an idea and then going to the literature to see if anyone has gathered data that would test it, finding a paper where it was tested, and the data agreed with my hypothesis better than it agreed with the hypothesis the authors were trying to test. Scientists who report their data accurately and precisely even when it does not agree with their hypothesis good scientists. Their work can be built upon because they have the intellectual honesty to report it accurately.

    Many people don’t have the intellectual honesty to be other than Cargo Cult Scientists. The people doing acupuncture with toothpicks who concluded that “toothpicks work too!” are Cargo Cult Scientists. They lack the intellectual honesty to truly look at their ideas and reject them when the data says to. At least they reported that toothpicks worked just as well. People with greater intellectual honesty can look at the data and appreciate that it says that acupuncture is a placebo.

  81. SD says:

    Dr. Novella:

    “But there is a third category in the plausibility spectrum – treatments that are inherently implausible. These are treatments that not only lack a known mechanism of action, they violate basic laws of science. Homeopathy violates the law of mass action (a basic principle of chemistry), the laws of thermodynamics (extreme dilutions maintaining the chemical “memory” of other substances), and all of our notions of bioavailability and pharmacokinetics.”

    Well, hold the phone there, Trigger. I’m not going to defend homeopathy, but there’s a dangerous attitude lurking here beneath the surface that demands attention.

    First of all, the laws of thermodynamics do not exclude the concept of homeopathy. Changes in internal microstates of matter show up as energy differences, true; however, I doubt anybody has done a calorimetry experiment on homeopathic dilutions to see if any show up, and even if they have, the ensemble containing a plausible reactant comprised of water molecules (see below) may not necessarily be far enough away, energetically speaking, from the ensemble containing “random orientations” of water molecules to be detectable outside of experimental error.

    Second, the law of mass action only applies if you are considering the important reactant to be the substance being diluted. If you forego this assumption – see below – it no longer applies.

    The deadliest thing to the scientific process is what the scientist *thinks* he knows. We think we know many things about how the universe works, and many of them are actually useful; however, we are perpetually surprised when new descriptions of internal mechanics come along which elucidate unknown processes, or describe them differently enough that the immediate response is “Bullshit!” Most of the scientific discoveries of the 20th century had no rational or “plausible” precursor; many of them (quantum mechanics being the prime example) are thoroughly counter-intuitive. Nevertheless, these theories are true, within experimental error… until something better comes along. People are working hard on that “something better” right now. In order to achieve the goal of a better theory, it is frequently necessary for them to discard what they think they know about how the world works in order to achieve a deeper understanding of how the world *actually* works. Maintaining a healthy level of skepticism in *your own* understanding of how the world works is the key to the scientific mindset. This is not an argument for keeping your mind so open that your brain falls out both ends, of course.

    (Yeah, I’m skating perilously close to woosprech here, but y’all *know* it’s true. Breakthroughs do not happen when you apply the old paradigm; breakthroughs happen when you skate close enough to the edge of insanity that you can steal the holy madness of the gods in order to construct a consistent and testable hypothesis that blows the mind, without actually getting your mind blown in the process. Sometimes this works; we give these folks Nobel prizes. Sometimes it doesn’t. Sometimes they go nuts and wind up inebriated street bums, or in asylums. Nobody said questing after the secrets of the gods was without risk.)

    *Could* homeopathy work? I doubt it. I am less certain of this fact when I look at the existence of things like chemical waves, hydrogen-bonding and solvation effects, and apparently self-replicating simple molecules like prions (proteinaceous cellular automata). Water is funny. It *looks* simple, of course. Pry the lid off and start looking at how it actually behaves on different scales, though, and all the simple goes away real quick-like. The belief in nice and simple phase diagrams with straight lines for substances, and in comforting absolute descriptions of behavior that hold true on all scales from the nanoscale to the bulk, is something that is good for kindergarten phys/chem students to believe but does not have much bearing on Reality.

    Musing: What if some homeopathic substances *did* manage to produce, through solvation effects, a sort of self-replicating “water shell” which then propagated through the remainder of the solution, thereby permitting continued dilution while maintaining potency? (I’m not saying that it does, just proposing it arguendo.) This is not outside the realm of physical or chemical plausibility; water is a fascinating substance, and modeling its interactions with itself and other molecules is, ah, “complex”, to say the least. (As in, “requires zillion-dollar supercomputers to even think about, and for more than a handful of molecules, may require enough computing hardware to exceed the Chandrasekhar limit and collapse the Earth into a black hole”). Detecting such effects is also difficult. However, the notion that a “shape” may persist in solution is not a priori unthinkable.

    Entropic effects would tend to dominate, yes; “shapes” don’t last for long when confronted with thermal noise. Of course, entropy is a bulk phenomenon, not a microscopic or nanoscale one; also, if nothing else, life itself demonstrates that it is possible for self-replicating molecules (or self-replicating systems) to prosper in the presence of a forbidding entropy gradient. Modeling this would be, ahem, “difficult”, however. Knowledge of such processes is lacking.

    But scratch the knowledge requirement; let’s think about what effect such “shapes” might have. Would they do anything, when mixed with other molecules or administered to a human being? (Doubtful, but…) Would small clusters of water, more coherent than might be expected of a random globule of water at a given temperature, have any different “effects” based on its internal organization? Might they interfere with enzymes? Preferentially solvate some ions over others? What effects would this have in a clinical context?

    Might the failures of homeopathy be related to failures in the production process, due to the lack of ability to determine when the creation of such “shapes” has succeeded? Might it be due to a lack of process control, where temperature variations or contaminants “poison” such structures? In the presence of a series of random failures of production for homeopathic treatments, what results would clinical studies based on observation of external effects give? What would clinical studies for ordinary pharmaceuticals look like if the “treatment” arm of the study was given a substance that itself had a 50% chance of being placebo, and you couldn’t tell which was which even after unblinding?

    All of the above is handwaving, of course. Do I believe in homeopathy? No. What do I know about water? Quite a bit, compared to what “we” as a species know; nearly bugger-all, compared to what there *is* to know about it. I am, however, willing to spend five minutes dreaming up testable ways in which homeopathy *might* work.

    “Homeopaths therefore substitute any notion of chemical activity with a vague claim about “energy” – but this just puts homeopathy in the category of energy medicine, which is just as implausible. Invoking an unknown fundamental energy of the universe is not a trivial assumption. Centuries of study have failed to discover such an energy, and our models of biology and physiology have made such notions unnecessary, resulting in the discarding of “life energy” as a scientific idea over a century ago.”

    I wouldn’t rag on them for their misuse of terminology; medicine has its fair share of boner-riffic terminology missteps, as does science as a whole. (Why is it called “organic chemistry”, again? Still referring to “herd immunity”?)

    “Energy” has a fairly well-defined physical meaning, yes. Technically, it might even be appropriate; T dS (temperature * differential entropy, the latter being appropriate for discussing internal changes in organization of matter) has units of joules, and is considered a component of total energy. So, assuming any of the above speculation was true (and I’m not holding my breath), they might be “accidentally right”.

    I suspect they’d probably get further if they framed their models in terms of structure and information; it might have a salutory effect on their thought processes.

    “nasrudin was looking for his keys beneath a streetlamp…”
    -SD

  82. tm says:

    Lawrence C.: Amen. As a former bad physics student, I know I’m in the presence of woo-based medicine when I hear a reference to quantum anything relating to biology or medicine.

    You know if physics was an anthropomorphic entity, it might respond thus:

    Dear “Alternative” “Medicine”:

    We’ve never met. But your little devotees keep talking like we’re good friends. We’re not. For the record, I don’t have good friends, because everyone else is an idiot. Especially Mathematics, what a freak.

    Anyway, it seems like you want to be taken more seriously, “like a science”, you say. Well, you’re not a science, so suck it up and go away. It’s not my problem that you can’t pass actual scientific rigor. Or provide anything useful or objectively beneficial. Those twits, Chemistry and Biology, have managed to do even that basic task. They’re not as beautiful or as smart as me, but hey, who is?

    But for crying out loud, quit referring to my awesome theories (which, ok, are broken, but at least they form the basis of modern civilization), to lend you credibility. Especially when you can’t tell the difference between momentum and yo momma. Why do you always talk about quantum, when you clearly only learned about it from Philosophy? And that guy, he’s even more out to lunch than Mathematics and is a complete idiot to boot. Ever since the 1960s, he’s been all, “duuuude, this quantum…” and by “quantum” he actually means quaaludes.

    Every time you try to associate yourself with me, you forget that I SPEAK MATH. It’s what I do, since, guess what, the Laws of the Universe are WRITTEN IN MATH. Guess what’s missing whenever you tell people how you’re good friends with me?

    THE MATH. That’s what’s missing, moron. At least Mathematics can hold an intelligent but unnatural conversation. You’re still trying to figure out what 2+2 is.

    Remember, we’re the ones that can wipe out life as we know it, so get your act together and quit trying to associate with me. No, I won’t be your facebook friend.

    Go away,
    Physics

  83. micheleinmichigan says:

    Alison, thanks so much for the link.

    http://autismcrisis.blogspot.com/search?q=preschool

    It was a really interesting read. I think that I have come across the author on some other web search, she also had many interesting things to say, then.

    The neurodiversity movement reminds me a lot of the controversy in the deaf community. In the deaf community two major controversies are the use of cochlear implants in children and communication methods that parents chose. My opinion in that area is that ultimately all a parent can do it try to look at all the information available and try to make the decision that will be in the best interest of the child today and in adulthood. In the instance of hearing impairment, the controversy (although sometimes upsetting) can serve the parents because it makes the information they need to consider all sides the most available.

    I think the same is true for autism and neurodiversity. But the one problem is, there is less information available to parents. At this point autism appears to be a far more complex diagnoses, with much less predictable outcomes than hearing loss. I feel for the parents who have to make treatment decisions for the disorder today. But, I can’t help but think that folks like Michelle Dawson are providing a good service to parents in offering their perspective and skills with research analysis. I only wish that I had more data skills myself so that I could understand her more in depth remarks.

    My one quibble with this article would be – this line “While a great advantage of ESDM is reported to be that it is “fun to do!” in fact the manual sternly declares, when contemplating autistics who may enjoy learning in the wrong non-ESDM way: “Our job is not to keep children happy; it is to teach them their objectives.” And that very limited hierarchical range of objectives must be rigidly achieved in the one rigid proper manner and the one rigid proper order.”

    I feel that the author is suggesting that intervening in an activity that is making the child happy and replacing it with an activity that the adult feels is more appropriate is wrong and perhaps there is a suggestion that this is happens disproportionately to children with Autism. (I am open to another interpretation.)

    As a parent I have to say we do this all the time to NT children. I turn off the t.v. and tell them to go outside. I insist we walk to school when they would rather drive. I insist that they do not hit or yell at me, when that is what they want to do. I insist they do not interrupt me on the telephone (although, they do anyway). the list goes on and on. My question is what is the difference between interrupting a child stymming so that they can attend to a speech activity and turning off the T.V. so that a child can do homework?

    So to me the problem is not that a parent or therapist is choosing to teach the child, it is how it is done. My experience is that with any of the therapies “how it is done” (meaning how the therapist motivates the child, their attitude, their ability to monitor and set appropriate, non frustrating goals, etc) varies widely on the skills, personality and talent of the therapist/parent.

    I have had several speech pathologists work with my son using the same methods/philosophy. One I felt like I wanted to hit every time she talked to my son (it’s always best to stay away from those) Others were very nice but not challenging enough or too challenging. A couple have an incredible knack for getting him to happily participate in therapy and make good progress.

    I can only think that it would be similar with a child with autism and any number of safe (nonCam) therapies. The results and good will of the child will depend more on the skill of the therapist than the method used. But, that is only speculation based on personal experience.

    In conclusion, I also wanted to recommend the author’s observations on the organization of the control group in the study she discusses. She has some excellent points.

    (long,long,long comment. sorry.)

  84. micheleinmichigan says:

    TM – I am not a physicist or even good at math, but I am still chuckling. Thanks

  85. TM on “Alternative” “Medicine”:
    “Go away.”

    Hee!

    michele,

    Yes, we could go on and on and on about autism and autism research and what it means. I’m sure there’s a blog out there for that!

    Michelle Dawson is very autistic. She can’t cook without placing herself in great danger. She doesn’t have furniture. She was too autistic to work as a letter carrier for Canada Post (she couldn’t adapt to changes in her route without two months of preparation; her affect and self-mutilation scars were distressing to other employees). So now she works as a researcher at the U of M. That’s work that engages her autistic strengths and she’s well-respected. She even does things like host panel discussions and make presentations at colleges, things that one would think would be difficult for someone who is very autistic.

    She has a particular point of view. She recognizes that autism is disabling but recognizes that it confers strengths as well. She’s concerned that interventions for autistic children to make them less autistic are promoted as their only hope to avoid disaster for them and their families and the society they burden: she takes this very personally as a statement that as a very autistic person, she is herself a disaster and represents a disaster for society. As a scientist, she wants to document whether interventions that are claimed to make children less autistic cause them to lose autistic strengths as well as gain NT skills.

    You might also like Joel Smith’s blog, NTs are weird. I particularly like his entry about how to have a creative and fulfilling sex life when you and your beloved are both autistic and have sensory issues. http://thiswayoflife.org/blog/?p=360 . It’s especially touching when you compare it with his essay on the paradoxical appearance of disability in autism http://www.autistics.org/library/youhaveitsogood.html .

    As a parent, you have to make decisions for someone else with insufficient information. I think that’s the hardest thing about parenting anyone; parenting a child with a poorly-understood disability is even harder. The good news is, you can still be a good parent even if you make mistakes.

  86. micheleinmichigan says:

    “So now she works as a researcher at the U of M”

    Drat, I was just going to claim her for my alma mater University of Michigan, when I noticed that her blog states University of Montreal. But I guess I will have to continue to check her out, in spite of my michi-centric beliefs.

    “It’s especially touching when you compare it with his essay on the paradoxical appearance of disability in autism http://www.autistics.org/library/youhaveitsogood.html .”

    I don’t think I can express how deeply this affected me. I also don’t think I would ever be brave enough to write something like this.

  87. Lawrence C. says:

    TM,

    Thanks for that funny letter to Alternative Medicine. I especially appreciate Physics calling Mathematics a “freak” and then boldly declaring that is Physics’s preferred language. That’s it, exactly! A strange, wonderful and peculiarly impassioned relationship between those disciplines, one that “alternative medicine” people neither get nor “grok,” to steal a famous literary term.

    I think some of the “alt” folks also mistake those poetic descriptions of realities (Michio Kaku’s works, etc.) derived from yet another language (mathematics) that itself describes nearly inconceivable realities to be those inconceivable realities themselves. “The map is not the territory” as another writer might say. But the “alt” folks take the descriptions of the map of the map of the territory and think they’re looking at the way things somehow “truly” appear in the everyday world. This is perhaps a good thing if it makes one consider the nature of perception but a very bad thing if this poetic-sounding world is used to sell quack treatments and bogus pills.

  88. JMB says:

    @SD “Most of the scientific discoveries of the 20th century had no rational or “plausible” precursor; many of them (quantum mechanics being the prime example) are thoroughly counter-intuitive.”

    My only formal training in quantum mechanics was about 3 weeks worth in physical chemistry, so obviously I am lacking in knowledge, and was subject to the oversimplification for teaching. Feel free to correct and educate me. I was under the impression that the development of quantum physics came from the search for a mathematical description of a reproducible experiment, the spectra of black body radiation. The mathematical description was plausible because it successfully matched the observed spectra. The implausibility came from the interpretations of the equations, and the corollaries of the theory. So I think quantum mechanics passes the test of plausibility that is being recommended by SBM (your corrections welcome here, I will always be a student). But the key concept here is not that quantum mechanics sounds implausible when we try to describe it, but that the development of the theory was based on plausible explanations of observable phenomena. Of course, maybe that is just the oversimplified version.

    Unfortunately in medicine, the application of the arguments of rigorous limitations of scientific validity opens the door to quackery (because we really know so little). I think SBM definitely needs a multidisciplinary approach to counter the limitations of college level science education. But we also need to keep an eye on the distinction of whether we are talking about medical science, or medical practice. In medical science we must deal with what is theoretically possible. In medical practice, we must deal with what is theoretically likely.

  89. BillyJoe says:

    SD

    “nasrudin was looking for his keys beneath a streetlamp…”

    …what keys? Nasrudin was driving a horse drawn buggy!

    SD struggling with himself:

    I don’t think homoepathy is true but…it might possibly work this way…or have you considered this admittedly unlikely possibility…or maybe this almost complete impossibility….or maybe if things were different things would be different and therefore….or if the paradigm shifts….and,hey, the quantum is oh so counterintuitive so just maybe…but, no, I don’t think homoepathy works…but, wait a minute, what if…

    :)

  90. daedalus2u says:

    When ever someone uses uses the term “counterintuitive”, all that tells me is that they have crappy intuition. Intuition is only a tool for hypothesis generation, or a substitute for thinking based on facts and logic when there are not enough facts, or when there are too many facts to connect together in a closed form logical argument. If your intuition does not correspond with reality, your intuition is faulty and you have to change your intuition.

    I see “intuition” as a non-algorithmic way of thinking, to contrast with the algorithm of deductive logic. Many organisms have the ability to estimate quantity by sight. Humans can do that, but humans who have learned how to implement the counting algorithm can also count and achieve an exact comparison of the two quantities.

    There is no need to try and figure out a mechanism for homeopathy until there is a verifiable phenomena that needs to be figured out. There is none for homeopathy. As the rigor of the tests becomes better and better, the positiveness of the results declines. All the “data” associated with homeopathy is completely consistent with a placebo effect, wishful thinking, error and fraud. Until those ordinary explanations are excluded, we don’t need to posit extraordinary explanations such as persistent vibration states of water or alcohol or sugar. Which, by the way, thermodynamics does exclude. If a vibration state is to be stable at room temperature for the reported shelf-life of homeopathic preparations, it has to have a certain activation energy. The “energy” deposited by shaking is small (in terms of 3/2 kT) compared to thermal de-activation from months of storage.

    The only basis for homeopathy are the statements by someone ignorant of modern chemistry, Avogadro’s number, and thermodynamics. Someone who came to his conclusions not using tests that were blinded or well controlled. We know his data was insufficient for him to draw the conclusions that he did. There were no tests that he could do in the early 1800′s that would have been reliable enough to conclude that diluting something 10^500 times would result in something that had active properties.

  91. JMB says:

    I think the only disagreement that might exist here is how to frame the best argument to use against homeopathic “water memory”. From the clinical perspective, it is hard to believe that any detectable water shell would survive the high acidity of the stomach, or the turbulence of the microvascular networks of the body, or the heart. In a high output state, such as when somebody has a fever, or is actively exercising, blood can easily be flowing at 1 meter/second, which ought to insure the demise of any water shells. So I am curious, do any of you on this comment thread have a postgraduate degree in chemistry? I thought that SD might be a professor because he talked about oversimplification, something I felt I had to do back when I was teaching medical students.

  92. pmoran says:

    Daedalus2: “There is no need to try and figure out a mechanism for homeopathy until there is a verifiable phenomena that needs to be figured out. ”

    I agree. This is what is wrong with too much emphasis upon “argument from scientific implausibility”. Scientific debunkings, have their place, I guess, but they do imply that the questions are worthy of scientific consideration. They are not, on Daedalus2′s “verifiable phenomena” grounds .

    Keeping the discussion low-tech, on stuff that everyone is familiar with, may help more. Everyone knows that dilution and succussion does not increase the biological effects of their coffee, or of alcohol or of anything else. They can test that out for themselves.

    Everyone knows that people are suggestible and will feel better if told so, or that they will get better anyway from many conditions.

    Everyone can understand on some level that there is something screwy going on when literally dozens of fringy medical ideas are claimed to be able to cure allergies, and relieve arthritis, depression and anxiety, but they don’t seem to be able to help much with more major medical problems, or to dvance medical knowledge in novel ways.

    I sense from discussions with them that even many staunch defenders of CAM know this. They just hate it when we we sneer at CAM or seem to want to lord it over them, especially if seen to be plotting to prevent them from trying anything they wish when they have an unresolved medical problem.

    Most already consult doctors for anything important. They just don’t trust doctors and scientists sufficiently to pledge the total allegiance that we wrongly assume is ours by right rather than through the earning of their trust. And that’s probably OK, so long as we can get them to trust us when it does really matters.

  93. JMB says:

    I believe many of those therapies we group in CAM already have clinical studies to suggest an effect slightly greater than placebo effect (as you might expect 5% of the time). So while the evidence is weak, it gets harder to dismiss them with the argument of lack of verifiable phenomena, if you are talking about empirical results.

    I would agree that most patients will not be interested in the scientific arguments (some will). pmoran has the best approach to the patient.

    I apologize that I may have been mixing the different articles up, but I was also following threads in the Yale symposium article, and the CAM on campus article. My posts were shaped partly because I was trying to take advantage of free education from some of the other responders, but also to shape a response to the arguments of medical doctors pushing CAM or IM. Plausibility is a pivotal point in arguing for SBM beyond EBM. Patients rarely will care, but it is fairly central to the debate at Yale. It is important to have rigorous scientific arguments for that crowd (or this crowd here) to maintain credibility.

  94. BillyJoe says:

    jmb,

    “From the clinical perspective, it is hard to believe that any detectable water shell would survive the high acidity of the stomach, or the turbulence of the microvascular networks of the body, or the heart.”

    Quite apart from its survival from the water to the sugar pill!
    Most homoeopathic treatments are sold in pill form. A few drops of the water is placed on the sugar pill, the water evapourates, and the memory of water is transferred to the sugar pill. Or so the story goes.

    “believe many of those therapies we group in CAM already have clinical studies to suggest an effect slightly greater than placebo effect (as you might expect 5% of the time). So while the evidence is weak, it gets harder to dismiss them with the argument of lack of verifiable phenomena, if you are talking about empirical results.”

    Systematic reviews.
    Looking at individual trials is called “cherry-picking”. For every trial they can point to that shows an effect, there is another one you can point to that shows no effect.
    With systematic reviews you look at *all* the clinical trials, exclude that trials with fatal methodological flaws, and come to conclusions based on the totality of the reliable evidence.

  95. Patients rarely will care, but it is fairly central to the debate at Yale.

    Yes, that is the point, and not only because it would be aesthetically pleasing for medical schools to stop flirting with pseudomedicine, but because in doing so they would stop their annoying habit of implying—to patients—that such nonsense “might” be valid.

    @SD:

    As usual (I am probably the only SBMista to think this) your arguments are compelling to a point. The short answer is that “implausible” doesn’t mean “impossible,” although in the case of homeopathy it is very close.

    Consider: even if your scenario of self-replicating “water shells” were possible, how would they “know” to be the correct ones? Homeopathy isn’t only infinitesimals; it’s, well, homeopathy: like cures like (for which there is also no evidence, BTW). What about all the other stuff in the solution? Getting back to “water shells,” how would they “know” to respond to further dilutions by increasing (not merely maintaining) their numbers (or size or something) according to the number of dilutions, as is required by “potentization”? Kind of the opposite of what information theory would predict, no? (And again, those “shells” that have somehow descended from substances other than what the homeopath was intending had better “know” NOT to get potentized themselves, or there could be some serious drug collisions!) Eksettera.

    From a strictly scientific point of view, the prior probability of homeopathy is very close to zero. That it is not zero itself is an acknowledgement of the tentative nature of scientific theory—your plea. But to argue that the distance between zero and the infinitesimal PP of homeopathy—which, in addition to its false premise and molecular problems and clinical trial failures also fails to predict anything in nature—to argue that this is enough to justify medical schools coyly suggesting that it “might” work (see above), amounts to, well, keeping your mind so open that your brain falls out both ends.

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