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Tai chi and fibromyalgia in the New England Journal of Medicine: An “alternative” frame succeeds

It never seems to fail. I go away for a few days, in this case to combine fun with pleasure and pleasure with fun by giving a talk to the Chicago Skeptics and at the same time meeting my brand new (well, by this time three weeks old) nephew for the first time, and something always happens. Before I get to what happened, I just want to point out that the talk actually went pretty darned well. I was utterly shocked that it was pretty much standing room only, with perhaps 50 people there to hear me. Honestly, don’t you people have anything better to do on a beautiful Saturday afternoon in August? But, seriously, the whole thing was a blast, and the assembled skeptics there didn’t even let me off the hook, as at least a couple of them asked some fairly challenging questions, one of which, I must admit, I wasn’t prepared for. In any case, my thanks go out to Dr. Jennifer Newport, skeptical Chicago pediatrician extraordinaire and organizer of my talk and the party at her apartment afterward. Between the two events she raised hundreds of dollars for the vaccination drive going on at DragonCon this weekend, Chicago Skeptics, the Women Thinking Free Foundation, and CFI-Chicago for inviting me and being such fantastic hosts.

Back to business. Science-based medicine (SBM) business, that is.

What happened while I was away could almost be characterized by the New England Journal of Medicine (NEJM) singing “Oops, I did it again.” Three weeks ago, the hallowed pages of the NEJM hosted a truly execrably credulous review article about acupuncture. So bad was the article that it “merited” the incredibly rare triple beat-down from this very blog, with posts by Steve Novella, the ever-irascible Mark Crislip, and myself in rapid succession applying the clue-by-four. As I was preparing to leave for Chicago on Thursday, I happened to look at the very latest issue of the NEJM hot off the presses, and what to my wondering (and watering–it is ragweed season) eyes should appear but an article reporting a study on the use of tai chi in treating fibromyalgia. Entitled A Randomized Trial of Tai Chi for Fibromyalgia, the study comes out of the Tufts University School of Medicine and the Newton-Wellesley Hospital in Boston and was carried out by a team led by Chenchen Wang, MD, MPH. Not surprisingly, the study has gotten a lot of play in the media, for example, in this story in the L.A. Times, which is at least reasonably restrained, probably because it an AP wire story by Marilynn Marchione, who has written some excellent articles about “alternative” medicine before. Even the usually reliable GoozNews seems smitten with this study beyond what it rates, characterizing it as “rare victory for the National Institute of Health’s National Center for Complementary and Alternative Medicine and Sen. Tom Harkin (D-IA), who routinely comes under fire for pushing funding for these types of studies.”

I’m less impressed. You’ll see what I mean in a few minutes, I hope. First, however, let’s look at the study itself.

Fibromyalgia, like many chronic conditions, truly sucks. If there’s one condition or disease (or whatever you want to call it) that is poorly understood by medical science thus far, it’s fibromyalgia. Indeed, like some diseases that are also not well understood, there has even been some debate whether or not fibromyalgia exists as a distinct disease. Although that debate appears to have been largely settled in favor of fibromyalgia as a clinical entity, unfortunately, the pathogenesis and pathobiology of fibromyalgia remain “incompletely” understood (meaning not well understood at all), and there is considerable controversy over the precise diagnostic criteria to use to define the syndrome. The authors of this study describe fibromyalgia thusly:

Fibromyalgia is a common and complex clinical syndrome characterized by chronic and widespread musculoskeletal pain, fatigue, sleep disturbance, and physical and psychological impairment.

“Common and complex” usually means that a lot of people have it; we don’t understand it; and we don’t have any good treatments for it. An accompanying editorial by Gloria Y. Yeh, M.D., M.P.H., Ted J. Kaptchuk, and Robert H. Shmerling, M.D. entitled Prescribing tai chi for fibromyalgia: Are we there yet? describes fibromyalgia thusly:

Fibromyalgia is a common and poorly understood pain disorder that afflicts an estimated 200 million or more people worldwide.1 The lack of objective abnormalities detected on physical examination and standard blood and imaging tests has led many physicians to question the existence of this disorder.2 However, for those experiencing the pain and other associated symptoms (including fatigue, stiffness, and nonrestorative sleep), there is little doubt that the condition is real — and so is the need for relief. Studies over the past decade suggest that fibromyalgia may be due, at least in part, to an alteration in pain sensitivity in the central nervous system.3 Other potential mechanistic contributors include a genetic predisposition, emotional or physical stress, disordered sleep, and neurohormonal dysfunction.

These sorts of conditions are the most frustrating of conditions to deal with, particularly for patients but also for doctors. After all, no one goes into medicine to tell patients that there’s not much he can do for them; yet that’s what doctors all too often end up having no choice but to tell fibromyalgia patients. Not surprisingly, patients are neither happy nor satisfied with this, nor should they be. They’re suffering, and they want relief. Also not surprisingly they’re willing to try almost anything, including the rankest forms of quackery peddled by unscrupulous quacks.

Let me hasten to add right here that I am most definitely not saying that tai chi is a rank form of quackery pedaled by unscrupulous quacks. It’s a martial art that combines slow, deliberate, graceful stretching and isometric exercises with breathing exercises, relaxation, and visualization. I was merely using the reference to quacks to explain why it’s not surprising that physicians might consider tai chi as an intervention in patients with fibromyalgia, given that currently the standard interventions recommended consist of exercise, sleep hygiene, and medications. Unfortunately, all of these interventions have problems, particularly the pharmacological interventions, which in general aren’t all that effective. One might even say that demonstrating their efficacy to be greater than that of placebo interventions has been difficult. Although exercise is helpful in fibromyalgia, it is not known what kind, intensity, or combination of exercise modalities works, and, of the ones that may work, which one works the best. Tai chi, therefore, would appear to be at least as good a candidate exercise regimen as any because of its gentleness, requirement for control, and relaxation. It is not at all unreasonable to hypothesize that tai chi might benefit patients with fibromyalgia, although not for any reasons of “energy flows” or alterations of the flow of qi.

In this particular study, the design was fairly straightforward and is summarized below (click for a larger image):

Randomization

Basically, the study examined 66 patients diagnosed with fibromyalgia by the time randomization was complete, of which 33 were assigned to the tai chi group and 33 to a sham group that underwent stretching exercises. The specific tai chi intervention used for this clinical trial was described thusly:

The tai chi intervention took place twice a week for 12 weeks, and each session lasted for 60 minutes. Classes were taught by a tai chi master with more than 20 years of teaching experience. In the first session, he explained the theory behind tai chi and its procedures and provided participants with printed materials on its principles and techniques. In subsequent sessions, participants practiced 10 forms from the classic Yang style of tai chi18 under his instruction. Each session included a warm-up and self-massage, followed by a review of principles, movements, breathing techniques, and relaxation in tai chi. Throughout the intervention period, participants were instructed to practice tai chi at home for at least 20 minutes each day. At the end of the 12-week intervention, participants were encouraged to maintain their tai chi practice, using an instructional DVD, up until the follow-up visit at 24 weeks.

The control intervention consisted of this:

Our wellness education and stretching program similarly included 60-minute sessions held twice a week for 12 weeks.19 At each session, a variety of health professionals provided a 40-minute didactic lesson on a topic relating to fibromyalgia, including the diagnostic criteria; coping strategies and problem-solving techniques; diet and nutrition; sleep disorders and fibromyalgia; pain management, therapies, and medications; physical and mental health; exercise; and wellness and lifestyle management.20 For the final 20 minutes of each class, participants practiced stretching exercises supervised by the research staff. Stretches involved the upper body, trunk, and lower body and were held for 15 to 20 seconds. Participants were instructed to practice stretching at home for 20 minutes a day.

One can certainly argue whether the sham control intervention was an appropriate sham control or not. It would depend to some extent what sort of stretching exercises were included, as well as other factors, such as the quality of the instructional material and the attention paid to the patients by the wellness education instructor. Also, one might imagine that the self-massage part of the tai chi intervention might have some benefit. It’s hard to say.

What one can say about this is that there does appear to be a suspicious difference between the two groups. Note that the protocol specifies that one tai chi master with over 20 years of teaching experience instructed the tai chi group, while multiple members of the research staff did the control instruction. More worrisome, note that the control group only underwent 20 minutes of exercise during its 60 minute sessions. It’s not specified how long the tai chi group exercised during its 60 minute sessions, but it would not be unreasonable to speculate that most of the 60 minute session was spent doing tai chi. Be that as it may, there was no blinding at all, and it’s a pretty fair bet that the subjects in the tai chi group knew that they were receiving tai chi.

That problem aside, subjects were evaluated before starting the trial and then periodically for the severity of their fibromyalgia symptoms. The primary outcome measure was the change in the score on the Fibromyalgia Impact Questionnaire, a 100-point scale that estimates intensity of pain, physical functioning, fatigue, morning tiredness, stiffness, depression, anxiety, job difficulty, and overall well-being at 12 weeks. Secondary outcomes included the FIQ score at each week, as well as a number of other measures of fibromyalgia severity, chronic pain, and quality of life. Participants continued their regular medications and treatments, making note of any changes that occurred during the study period.

The results demonstrated improvement in FIQ scores in the tai chi group from 62.9±15.5 to 35.1±18.8, with an improvement in the control group from 68.0±11 to 58.6±17.6, with a highly statistically significant p-value. Investigators also noted improvements in other measures of pain and quality of life, all in favor of the tai chi group. More patients in the tai chi group had discontinued their medications to treat fibromyalgia by the end of the study period, but the difference was not statistically significant.

As you might expect, this study had a number of limitations. First, it isn’t very large. Another problem is that it looked at fairly short term outcomes. Fibromyalgia is a chronic condition for which 12 to 24 weeks do not represent a sufficiently long period of time to judge whether any potential responses will be durable. Previous studies have found that exercise can help fibromyalgia but that the effects are not always durable. This is particularly true given that fibromyalgia, like many chronic pain syndromes, is prone to placebo effects due to interventions, regardless of whether they’re effective or not. That’s one aspect of the condition that makes fibromyalgia so difficult to study.

More importantly, I must reiterate that this study was not double-blind. The authors justify this lack of blinding by arguing that there is no accepted and validated sham tai chi intervention. Fair enough. It took many years before scientists studying acupuncture managed to develop and validate various forms of sham needles that successfully blinded both patient and practitioner as to whether they were undergoing “true” or sham acupuncture. The authors also point out that investigators told study subjects that tai chi was being tested. Rather, they told subjects that they were testing the effects of two different exercise training programs, one of which was combined with education. Fair enough as well, but whether this “deemphasis” of tai chi worked or not to minimize expectations and placebo effects is highly arguable. Do the investigators really think that most of the tai chi group didn’t realize they were doing some form of “Eastern” martial art? Yeh et al sum up the difficulty in coming up with an adequate sham intervention for tai chi very well:

The authors state that they tried to minimize any a priori differences between expectations for tai chi and the control intervention, which consisted of stretching and health education, and they report that expectations in the two groups were similar at baseline. However, it seems likely that when a persuasive and enthusiastic teacher of tai chi first explained its potential benefits to the class, expectations in this group were heightened. The authors dutifully suggest that a sham tai chi intervention would have been desirable as a control. Ideally, a placebo control matches all aspects of the therapeutic intervention except for the “active” element of that intervention. But what is the active element of a complex, multicomponent therapy such as tai chi?11 Is it rhythmic exercise, deliberate and deep breathing, contemplative concentration, group support, relaxing imagery, a charismatic teacher, or some synergistic combination of these elements? If so, would the matched control include awkward movements, halted breathing, participant isolation, unpleasant imagery, or a tepid teacher? Would the resulting sham intervention be credible, valid, or even genuinely inactive?

These are all excellent questions. Unfortunately, Yeh et al then strongly imply that a “quixotic” search for the “ideal sham” would be a waste of time, which is rather annoying because such a search doesn’t have to be quixotic, nor would it be a waste of time. All you have to do is to break down tai chi into its key elements: the slow, graceful stretching and isometric exercises, the breathing exercises, the relaxation exercises. If it’s possible to break down tai chi into its important elements, then it would be possible to determine which aspects of tai chi are providing the benefit and which are not.

On the other hand, maybe Yeh et al have a point–except that they didn’t go far enough. I’ll show you what I mean.

Let’s for the moment and for the sake of argument accept the findings of Wang et al. Let’s say that tai chi is the greatest thing since sliced bread and that it alleviates fibromyalgia pain and stiffness better than anything we’ve yet come up with. Let’s assume all of those things are true, just for the moment and then think about it. What thought comes to mind to you? I know what thought comes to mind to me. In fact, I put this thought on a slide that I used when I spoke to the assembled throngs of Chicago Skeptics:

Alternative

That’s right. Why on earth is this result “provocative” (as Yeh et al describe it) or even the least bit surprising? Why on earth is it in the least bit “alternative” or “complementary”? Stripped to its essence and particularly stripped of its woo elements about qi, all tai chi is is exercise and relaxation, and we already know that exercise can be useful for fibromyalgia! The only question is what type, intensity, and regimen does the most good, and this study answers that question to the extent that it tells us that an exercise regimen resembling tai chi seems to work pretty well. Excellent! Science-based medicine can build on that! But why is this finding “alternative”? It shouldn’t be. Why was this study funded by the National Center for Complementary and Alternative Medicine (NCCAM) and why is it being touted by NCCAM (and GoozNews) as a “success”? It’s a study that had no reason to be done at NCCAM. It could have and should have been funded by the appropriate Institute in the NIH.

As I’ve written time and time again, exercise and relaxation interventions have been completely co-opted by the CAM movement as “alternative” when there is no a priori reason that they should be considered anything other than science-based interventions. Just because they are difficult to study doesn’t make them any less science-based. It just means they are difficult to study and that science has to work harder to validate them. However, CAM supporters know that co-opting less controversial modalities with some degree of prior plausibility that have no real reason not to fall under the mantle of science-based medicine allows them to slip the woo in alongside it. The Trojan horse is diet, exercise, and natural products derived from plants (i.e., herbal medicine). The Greeks jumping out of the belly of the horse are the woo, including acupuncture, “energy medicine” (including the “qi” aspect of tai chi), and even homeopathy. It also helps if the Trojan horse is something “Eastern,” because that’s so much cooler than ancient Western medicine, such as leeches and trying to balance the four humors, although apparently homeopathy, as German and therefore “Western” as it is, is still “cool enough.”

When it comes to the infiltration of quackademic medicine into medical academia, language and how various “alternative” or “complementary” treatment modalities are framed are everything. That’s how CAM can co-opt nutrition as somehow being “alternative.” It’s how CAM can claim exercise as being “alternative.” It’s how CAM can take the long-respected field of pharmacognosy, infuse it with the woo that is herbalism, and suddenly make the whole field suspect. None of these modalities should not be considered “science-based,” but CAM has claimed them as its own and used them as the Trojan horse to enter stealthily the bastions of medical academia. Once there, the horse disgorges the real woo, like acupuncture, reiki, and homeopathy, “integrating” quackery with science-based medicine until it’s hard to tell the difference between the two.

Posted in: Clinical Trials, Medical Academia, Science and the Media

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80 thoughts on “Tai chi and fibromyalgia in the New England Journal of Medicine: An “alternative” frame succeeds

  1. jmm says:

    It is “alternative” simply because it has a different history and culture. “Western” medicine involves certain institutions, training methods and cultural baggage, “alternative” methods involve different ones. Some of the alternative ones, such as tai chi, have prior plausibility and can be proven by science: I find this study very exciting in its results, and look forward to longer-term follow-up data. Some “Western” medicine turns out to be scientifically crummy, as many biased studies by the pharmaceutical industry attest to. Alternative vs. western and scientific vs. woo are two different distinctions.

    One of the key cultural differences with modalities such as tai chi and yoga is that THE TEACHER IS REQUIRED TO BE A SKILLED PRACTITIONER. This is currently alien to the Western medical culture. I suspect that one of the most powerful aspects of these modalities is their breathing practices. A few Western doctors (not nearly enough) may recommend deep breathing from time to time, for anxiety or for other conditions, but how many of them set aside an hour or more a day to practice what they preach? As a result, they are far less effective. There is a difference between prescribing and teaching. The cultural differences as to the manner in which care is administered are quite real, and quite independent of the question of whether a treatment is scientifically proven.

  2. David Gorski says:

    Alternative vs. western and scientific vs. woo are two different distinctions.

    Gonna have to beg to differ here. In fact, they are the same thing in practice and as used by promoters of pseudoscience.

    In fact, I reject completely the term “alternative” when applied to medicine or health. “Alternative” is far more a marketing term than any sort of useful descriptive term. Indeed, “alternative” medicine that has been shown to work through science ceases to be “alternative” and becomes just medicine. In essence, “alternative” versus “Western” means the same thing as woo versus science.

  3. mgoozner says:

    Thanks for calling me “usually reliable.” From David Gorski, that’s high praise indeed. I agree with your discussion about the limitations of the study. But as to your question about why the appropriate institute at NIH wouldn’t fund it, isn’t it obvious? It isn’t offered by the health care system nor is it reimbursed as health-related (unlike some gym memberships in forward-thinking health plans). Ergo, alternative. If not NCCAM, who?

  4. David Gorski says:

    NINDS. It is, after all, fibromyalgia.

  5. mgoozner

    You strongly imply that the NIH funds only studies for things that are currently “offered by the health care system” &/or reimbursed as health-related.

    Have you tried google lately, searching the terms “NIH nutrition research” or “NIH exercise research”?

    The NIH funds that kind of stuff ALL THE TIME. It’s not the National Institutes of Medical Practices or the National Institutes of Medical Reimbursements, it’s the National Institutes of Health.

  6. David Gorski says:

    Another example: Let’s not forget that the NCI also has the Office of Cancer Complementary and Alternative Medicine, which has the most unfortunate acronym ever for such a group (OCCAM). I realize that doesn’t help with tai chi, but OCCAM does have a budget roughly equal to that of NCCAM, around $120 million a year. Seriously.

    No, there is nothing “alternative” in tai chi the study of which cannot be studied by other NIH Institutes and Offices. Remember, NCCAM was an artificial construct created by Tom Harkin, not something requested by scientists at the NIH.

  7. Maz says:

    jmm, i have to take issue with your claim that western medicine is unfamiliar with the concept of a teacher being a skilled practitioner. I’m not even entirely certain what you mean by that statement, but I can’t think of any way to interpret it that makes sense.

  8. evilrobotxoxo says:

    As a psychiatrist, I can tell you that there is high comorbidity between somatizing/psychogenic pain syndromes and cluster B personality traits. I don’t know what the numbers are, but the relationship is pretty obvious to anyone who works in medicine. A lot of people with strong cluster B personality traits respond very well to meditation and mindfulness exercises such as those in yoga or tai chi, and that’s been a big part of the success of dialectical behavioral therapy in borderline personality disorder, which has a pretty respectable evidence base. In my admittedly limited experience with these cases, the pain syndromes can improve significantly when people learn better mindfulness and relaxation skills.

    I agree with all of Dr. Gorski’s criticisms of the study, and I think the way the media is promoting this as a victory of woo is ridiculous. However, if the results turn out to be correct, it could be due to the mindfulness skills developed in tai chi. This, of course, is pure speculation.

    And, obviously, it also raises a controversial point about how much of fibromyalgia is psychogenic…

  9. LovleAnjel says:

    If the study turns out to be correct, it is not a victory for woo. It is a victory for fibromyalgia patients and adds to the arsenal of science-based medicine.

  10. GinaPera says:

    Wonderful dissection. Thank you for your time in doing this.

    As someone who knows a bit about fibromyalgia, including how little most physicians know about treating it (including rheumatologists), I’d say this isn’t good news for anyone.

    Yes, we all need more stress and relaxation techniques, especially fibro patients. But to make these people’s lives center on these techniques just so they can keep muddling through, operating at half-speed instead of finding real treatment, well, that’s just abusive, IMHO.

    It’s just more palliative care that promotes the idea that there are no “cures” for fibromyalgia when, in fact, there are multiple avenues to more accurately pinpoint the contributory factors to this shamefully made bucket diagnosis.

    A “cure” isn’t going to happen, though, until a heightened focus is made on functional medicine, including examining nutritional deficiencies (such as magnesium, manganese), contributory neurotransmitters and their precursors/metabolites, and so forth.

    We’re taken stress-reduction techniques as far as they can go. While those are helpful in the short term — especially insofar as lessening the awfully helpless feeling many fibro patients carry around on a daily basis — fibro patients need real answers and real treatment.

    And what REALLY drives them nuts and even “hysterical” is for a psychiatrist to say their problems are psychogenic, when the implication that the genesis of their pain and fatigue is psychological or emotional conflict rather than not significant and obvious metabolic dysfunction.

    Unfortunately, fibro seems to have become one of those epidemic illnesses that invites discipline bias, and thus ensures that an integrative, science-based approach will not happen.

  11. jmm says:

    Maz, I am not denying that the doctor is a skilled practitioner of diagnosis and decisions about treatment. I mean the doctor is not a skilled practitioner of whatever the patient will be asked to do as part of their treatment. For most of Western medicine, this means taking a pill or passively undergoing surgery or other procedures. No skill is necessary on the part of the patient, so no issue arises.

    But breathing practices, mindfulness training etc. are quite different. To teach tai chi or yoga, one needs to practice tai chi or yoga. If the causal agent is, eg, some species of meditation, one needs to practice meditation to teach it effectively.

    This model of a health provider practicing what they preach is just not there within Western medical culture. There is no reason, however, for it not to be scientifically provable as essential for certain treatments. This is why I think that there is more to the Western vs alternative comparison. This leads to a bias according to which doctors are less likely to prescribe certain treatments that they are not competent to administer (ie teach), no matter what the evidence. And the fact is, although NIH might fund studies like this through regular channels, the insurance system is a long way from negotiating with and reimbursing tai chi teachers, no matter how effective science might prove them to be. That fact is a part of Western culture, not a part of science.

    Interestingly, one hint of an exception to all this is psychoanalysis, for which I believe the analyst is required to be psychoanalyzed themselves.

  12. evilrobotxoxo says:

    @Gina:

    I want to clarify a few things about the term “psychogenic.”

    Personally, I would not claim that fibromyalgia per se is psychogenic. I know it’s a matter of significant debate in the field, but one thing I’ll say is that in my experience, a significant proportion of patients in the community who carry fibromyalgia diagnoses (appropriately or not) have a significant psychogenic component to their pain syndrome.

    But as far as the term “psychogenic” goes, you say “when the implication that the genesis of their pain and fatigue is psychological or emotional conflict rather than not significant and obvious metabolic dysfunction.” This is simply an inaccurate description of what the word “psychogenic” means, and an inaccurate description of psychiatric disease in general. The difference between neurology and psychiatry, to a zeroth-order approximation, is that neurology deals with abnormal patterns of brain activity arising in the presence of a visible lesion, while psychiatry deals with abnormal activity patterns when no lesion is visible. This is a bit of an oversimplification, but to say that a pain syndrome is “peripheral” means that it’s an abnormality at the level of the nerves before they enter the spinal cord. To say that it’s “central” typically means that it’s inside the brain or spinal cord, and there’s some sort of readily identifiable anatomical or physiological abnormality. To say that it’s “psychogenic” means that it’s inside the brain and spinal cord, but that it’s a neurophysiological abnormality that’s not easily measurable using the crude tools of the clinician. It does NOT mean that it’s somehow caused by emotional conflict, “all in your head,” or in any way less real. Psychiatric illness is illness of the brain, period. I think that the inability of physicians and scientists to communicate this to the public, and the public’s inability to understand it, is part of what leads to stigmatization of “psychiatric” diagnoses. And this stigma leads to patients refusing to accept psychiatric diagnoses, even when they’re accurate, and not getting the help they need.

  13. Alexander Han says:

    From a less psychiatric perspective on psychogenic illness, just because something is psychogenic does not mean that its symptoms aren’t real. Panic attacks are usually psychogenic, and the increased heart rate is 100% real. Significant and obvious metabolic dysfunction is stuff like diabetes, where you can grab a needle and get the elevated blood sugar back in seconds, or grab an ophthalmoscope and see the retinopathy with your own eyes. The fact that fibromyalgia is not obviously metabolic, or even obvious, is not a comment on its significance or insignificance. Dismissing psychogenesis as a possible cause or contributing factor doesn’t help anybody – if you don’t think it’s important to the etiology, show your evidence ruling it out.

  14. Zoe237 says:

    OCCAM… ha ha.

    So if tai chi is medicine, can the instructors be called doctors? Serious question.

    I dunno, I read this in the papers and was hoping Gorski would take a crack at it. I expected more like a ripping apart of the study, so thanks for addressing this! This site definitely offers something one can’t find in regular newspapers.

    Does NIH have a history of funding studies like this? Is it possible other routes were tried before NCCAM?

  15. What’s considered “alternative” is an interesting question. If a study showing that the use of service dogs reduced medication use and pain scale scores in patients with MS, would service dogs be considered “alternative” medicine?

    As I see it, Tai Chi instructors, like service dog organizers and trainers don’t fall within the traditional medical field, they are not doctors and do not have a medical degree. They could be considered useful experts. Also, in both cases we can see scientifically plausible reasons why Tai Chi and service dogs may be helpful

    The two differences I see between service dogs and Tai Chi are these. Firstly, service dogs are mudane, Tai Chi is exotic, to American’s at least. Secondly, service dogs organizers have never competed with the mainstream medical field, where as Tai Chi’s association with Chinese medicine gives the possible impression of being in competition with mainstream medicine.

    I would gather that those two differences are what causes the press and some part of the public to peg Tai Chi as “alternative”. Is it a useful distinction? Not so much, in my book.

    I would have to say that I think the term “complementary health” or similar would be more accurate. The idea being, it is a field of expertise outside of medicine that can collaborate with medicine to improve the health of the patient.

    As a layperson, my next questions would be, how are these areas* currently handled in terms of research funding and insurance payment? Is there a need for improve?

    *not service dogs and tai chi, per se, but tertiary health fields in general.

  16. David Gorski says:

    I dunno, I read this in the papers and was hoping Gorski would take a crack at it. I expected more like a ripping apart of the study, so thanks for addressing this!

    It’s rather hard to rip apart a study like this when this study wasn’t actually that bad. It was an OK, but not outstanding, study. I have little doubt that if it weren’t tai chi there’s no way in hell it would ever have been considered high enough quality to have been accepted to the NEJM, though. Damn. Now that I think of it, I should have mentioned how the “alternative” label had propelled a so-so study into a journal far higher than it deserved to be published in on merits alone.

  17. trrll says:

    jmm, the study didn’t address the level of skill required for the instructor. They chose a highly skilled instructor, which is reasonable for what is still an exploratory study designed to determine whether or not Tai Chi can work better than a standard therapy. In fact, if this is not some kind of placebo effect, it is unlikely that it requires a high level of skill on the part of the instructor. There are certainly aspects of Tai Chi (pushing hands, for example) where it is important to train with a master. But the aspects of Tai Chi that can be taught to beginners in such a brief program are not ones that take a long time to learn.

    If I were to do the follow-up study, the next step would be to have a physical therapist (or even better, several) train in Tai Chi for a few months, and then have them run the class, teaching it purely as a set of physical exercises without reference to the history or tradition of the art. My guess is that it would work about as well.

    GinaPera, the fact is that new cures are few and far between in medicine. There are no reliable cures for HIV, Alzheimer’s disease, Parkinson’s Disease, many cancers, etc. And these are all much better understood than fibromyalgia. So a cure could well be decades away. In the meantime, there are people who are suffering now. There is no reason to believe that refusing to study palliative approaches will make the cure arrive any sooner.

    Note also that there is overwhelming evidence that the perception of pain, even pain from a verifiable peripheral cause, depends upon emotional state. So investigating palliative strategies that may (or may not) act by modifying mental state does not imply any judgement on the etiology of the syndrome.

  18. jmm says:

    trrll, I agree with you that this would be a good follow-up study, although I think it should have 3 groups, a tai chi master, a physical therapist, and a placebo along the lines of what they used here. I suspect the physical therapist would be slightly less effective over this timescale, although it may not show up as statistically significant in a small trial. But in terms of long-term results, which is what is really important for this disease, if these patients are going to keep doing tai chi and keep feeling the benefits, a physical therapist would not be able to do this.

  19. geo says:

    You said:

    “These sorts of conditions are the most frustrating of conditions to deal with, particularly for patients but also for doctors. After all, no one goes into medicine to tell patients that there’s not much he can do for them; yet that’s what doctors all too often end up having no choice but to tell fibromyalgia patients. Not surprisingly, patients are neither happy nor satisfied with this, nor should they be. They’re suffering, and they want relief. Also not surprisingly they’re willing to try almost anything, including the rankest forms of quackery peddled by unscrupulous quacks.”

    This is quite true. Unfortunately, these frustrations have led some Doctors who consider themselves to be promoting Science-Based-Medicine to descend to utter quackery – not only betraying their patients, but also undermining their respect for science and likely pushing them to other forms of quackery as well.

    One such quack baldly asserts online that:

    “Forms of somatization today, such as MCS, CFS, most fibromyalgia, are the partly socially determined symptom complexes of what 100 years ago took the form of conversion (hysterical paralysis, blindness, etc..) The interaction between affected persons, the social environment and physician thinking and “style” has been studied by psychologists and sociologists and recorded by researchers from Charcot and Freud’s times through today.. The general theory states that people’s somatic focus changes to fit whichever syndromes physicians most likely regard as “real.” In other words, physicians and medical research terminology exude cues as to which symptoms may generate the most authenticity.”

    And then follows it up with:

    “To those who still must argue that CFS and related disorders are diseases and not somatiform illnesses, and to patients who deny their problems’ origins, allow me to drop the fomalities of physician behavior and to speak in language used here.
    You are wrong. Stop looking for information that fits your conceptions, and try to learn what is happening to you; how your life – the only one you may have – may slip away under a pall of unhappiness and contrariness, while disallowing entry to sources that may help you the most. There is hope if defenses relent, and none if they are maintained. ”

    Whatever the causes of these frustrating illnesses, we must wait for clearer evidence to emerge before drawing our conclusions and then imposing them on others, especially given the damaging affect that unfounded claims of psychological disturbance can have upon patients and the way they are treated by others.

    I do hope that the writers at science-based-medicine will do more to tackle those forms of quackery that try to hide behind the respectability of science, as well as those that are more explicitly super-natural.

  20. GinaPera says:

    Thanks for clarifying, Evilrobot. But please understand that “psychogenic” is a very imprecise term, which is why I offered one of its possible meanings as the one I take issue with.

    Still, I find it another “dualistic” misperception when psychiatrists view an illness is “in the brain” by definition has no relation to the body. This is the tragic flaw in most modern psychiatry.

    A “body” (which, last I looked, included the brain) is dependent upon many building blocks in order to function healthfully. Therefore, a “body” that is deficient in say, iron or B vitamins or magnesium — or even amino acids — will typically manifest in “psychiatric” illnesses as well. Whether or not we know this depends on how well we can measure the physiological anomalies or evidence.

    Yes, of course, some psychiatric illnesses are neurogenetic. But in my experience, fibro is a condition where we feel the full thud of modern medicine’s deficiencies. And, unfortunately, that too often means that women are sent to psychiatrists for their physical complaints instead of given full metabolic workups.

  21. GinaPera says:

    trll wrote:
    GinaPera, the fact is that new cures are few and far between in medicine. There are no reliable cures for HIV, Alzheimer’s disease, Parkinson’s Disease, many cancers, etc. And these are all much better understood than fibromyalgia. So a cure could well be decades away. In the meantime, there are people who are suffering now. There is no reason to believe that refusing to study palliative approaches will make the cure arrive any sooner.

    ———-

    The “cure” is HERE — for many, at least.

    I’ve already explains. “Fibromyalgia” is far too often a bucket diagnosis that abjectly fails to take into account mineral deficiencies, neurotransmitter issues, and the like. We know that now. Because I know many people who have recovered from “fibromyalgia” with the aid of wise physicians. (Yeah, yeah, “but that’s anecdotal!”)

    The other fact is, there are too many “specialists” who want more complex answers. They don’t want to lower themselves to the level of learning about magnesium, for petesakes! Or learning what an amino acid is! Or learning about copper overload. That’s just too…..plebian. That is NOT why they went to medical school!

    There is no glory to be had in such hum-drum “old wives tale” remedies. They want something sophisticated. Something rarified. A new drug maybe! Ohhh, or maybe a virus! Oh, yes, that sounds very interesting.

    Then again, they want a “cure” they can apply to EVERYONE who allegedly has fibromyalgia, because they don’t want to have to study basic science and use their brains, not to mention take risks (however benign) in seeing what might work. They might look…..oh, uncertain, or not very smart.

    Nope, as long as this kind of “thinking” dominates the discourse on fibromyalgia, women especially must seek out “alternative medicine” practitioners because mainstream medicine practitioners are routinely ignorant of what it takes to keep a body healthy.

  22. wertys says:

    @Gina Pera

    Your last post seems typical of many we have here from time to time. You are happy to impugn the motives of ‘the mainstream’ and rant about what ‘they’ are doing. You come right out and say you know what a ‘cure’ for FMS is, but you deny that anyone else can even find it.

    Perhaps you could link to some information about your ‘cure’ so it can be given the level of scrutiny we believe in at SBM, without the conspiracy-style nudges and winks.

  23. GinaPera says:

    I have no doubts some here will see this as “quack” medicine, but if you have fibromyalgia you might be more interested in remedies that aren’t going to hurt you. For that, I’ve found that Dr. David Edelberg, at Whole Health Chicago, has the best understanding of fibromyalgia that I’ve seen anywhere. And it’s not taking a tai chi class.

    This post is the last in his five-part series for a newsletter:

    http://www.wholehealthchicago.com/knowledge-base/f/fibromyalgia-an-almost-natural-approach/

  24. wertys says:

    @geo

    I agree with your view about how otherwise scientific practitioners will drink the Kool-Aid when faced with particular diagnoses, of which FMS is definitely one. It is very frustrating to see your colleagues fall for cognitive traps that you had thought they might be informed enough to avoid. I think yiou learn a lot about someone from looking at which set of irrational medical beliefs they fall for !

  25. wertys says:

    http://www.ncbi.nlm.nih.gov/pubmed/19250003

    http://www.ncbi.nlm.nih.gov/pubmed/17515022

    These are the only 2 clinical trials I can find which examine the micronutrient approach for FMS. The first is a relatively sound trial which was fairly small and gave a negative result. The second is an unblinded, very small pilot study with poor methodology and an inconclusive result which some may interpret as positive. Neither is particularly good evidence for a micronutrient approach to FMS.

    I note that Dr Edelberg recommends taking no fewer than 9 supplements which are conveniently available from his online store.

    I also note that Dr Edelberg is familiar with the American Pain Society guidlines for Fibromyalgia Syndrome, which are evidence-based, but he only refers to them for medication purposes. The guidelines actually contain a lot of information about what Gina Pera sneeringlky refers to as ‘palliative’ treatments that have a very robust evidence base. The link to them is here

    http://www.ampainsoc.org/pub/fibromyalgia.htm

    My conclusion is that Dr Edelberg appears to be using the ‘Integrative’ label as an excuse to provide his favourite treatments that don’t have any evidentiary support, but which can make some money. This sort of person is occasionally referred to as a ‘quack’.

  26. evilrobotxoxo says:

    @GinaPera

    “Still, I find it another “dualistic” misperception when psychiatrists view an illness is “in the brain” by definition has no relation to the body. This is the tragic flaw in most modern psychiatry.”

    I don’t know what to say, Gina. This isn’t just factually incorrect, it’s the opposite of the truth. I’m not sure if you’re confusing psychiatrists with psychologists, or maybe you (like most people) think that psychiatry involves a lot more psychology than it really does. But all psychiatric diagnoses are diagnoses of exclusion, and psychiatrists are first and foremost medical doctors. All patients seen by any competent psychiatrist see get full metabolic and medical workups if there’s any possibility that non-brain-related medical causes could be contributing. This includes a complete blood count (which typically picks up iron deficiency as well), metabolic panel (mineral concentrations), liver function tests, thyroid function tests, urinalysis, urine drug screen, etc. When it’s appropriate, things like B12/folate levels are checked, along with things like copper/ceruloplasmin levels, syphilis or lyme antibodies, HIV test, EKG/echo, etc. Basically, it includes everything you’re saying that we ignore.

    The point I want to stress is that being referred to a psychiatrist does not mean that the symptoms or the illness are “all in your head,” due to bad relationships with your parents, latent homosexual urges, or anything along those lines. It simply means that one doctor thinks that a different doctor would be more capable of helping you.

  27. evilrobotxoxo “All patients seen by any competent psychiatrist see get full metabolic and medical workups if there’s any possibility that non-brain-related medical causes could be contributing. This includes a complete blood count (which typically picks up iron deficiency as well), metabolic panel (mineral concentrations), liver function tests, thyroid function tests, urinalysis, urine drug screen, etc. When it’s appropriate, things like B12/folate levels are checked, along with things like copper/ceruloplasmin levels, syphilis or lyme antibodies, HIV test, EKG/echo, etc.,

    Really? I’ve meet with at least two psychiatrist, and know many other friends/family who have seen psychiatrists, sent by social workers or psychologists for medication consult. I have never experience or heard of any such work up, nor did they ask to see previous medical records or test results. In my case the psychiatrists did interviews that were obviously to rule out bipolar, suicide intentions and psychosis as well as asking questions about my psychiatric symptoms and life style (exercise, drinking, drugs).

    I can not speak to whether these doctors were competent or not. But, from a laymen’s perspective, I have come to believe that just because doctor diagnosing a particular condition should be following a certain standard of care, does not mean that the majority are. I’d have to see evidence that the majority of psychiatrists follow your procedure. I’m skeptical.

  28. evilrobotxoxo says:

    What I said was that a workup is done if there is any reason to suspect underlying medical causes. If someone comes in with physical pain, which is what Gina’s post was about, that would certainly be a reason. However, doing expensive workups that are not indicated is bad medicine. For a healthy non-elderly person coming in with routine depression and/or anxiety, for example, doing a medical workup may be unnecessary in the absence of symptoms indicating an underlying medical condition (e.g. hypo/hyper-thyroidism). Also, there’s frequently an internist involved, and they often handle that side of things, but the two doctors will often speak to each other.

  29. “All patients seen by any competent psychiatrist see get full metabolic and medical workups if there’s any possibility that non-brain-related medical causes could be contributing.”

    I might word that less unambigously, like so:

    “Most patients seen by competent psychiatrists get appropriate metabolic and medical workups if there’s a reasonable likelihood that non-brain-related medical causes could be contributing.”

    When I see a GP about depression, I get a thyroid function test. I don’t recall getting referred for a thyroid function test by my psychiatrist, but maybe I just forgot because it was a long time ago.

    I’ve never had a urinalysis when presenting with depression.

  30. evilrobotxoxo says:

    @Alison

    I certainly didn’t mean to imply that urinalysis is part of the workup for depression. My point was that every aspect of what Gina claims is being ignored by modern medicine is actually tested for in some case (but not for all of them). Urinalysis is part of the workup for acute mental status changes, particularly in the elderly, and it’s used more frequently in the inpatient setting.

    Thyroid tests should be part of the workup for depression, and I have referred plenty of people for them. However, it depends a lot on the setting, clinic vs. private practice vs. hospital, etc. Most patients with depression, for example, are seen by primary care first, who do a basic workup including TFTs and usually prescribe an SSRI, with treatment-refractory cases referred to a psychiatrist after medical causes are ruled out.

  31. trrll says:

    @GinaPera

    “I’ve already explains. “Fibromyalgia” is far too often a bucket diagnosis that abjectly fails to take into account mineral deficiencies, neurotransmitter issues, and the like. We know that now. Because I know many people who have recovered from “fibromyalgia” with the aid of wise physicians. (Yeah, yeah, “but that’s anecdotal!”)”

    Yeah, Riiiiight.

    Fibromyalgia is one of those conditions where symptoms can vary in severity over time quite a bit, which means that there will inevitably be a large placebo effect. So anecdotal reports and uncontrolled studies are worse than worthless.

    I find it particularly revealing that you criticize a treatment study that, while small and limited in a number of respects, at least includes a reasonable control group, and then direct us to a web site hawking the usual (highly profitable for the “practitioner”) nutritional woo, which so far as I know has not been shown in any controlled study to be effective for the treatment of any condition whatsoever.

  32. evilrobotxoxo
    “What I said was that a workup is done if there is any reason to suspect underlying medical causes. If someone comes in with physical pain, which is what Gina’s post was about, that would certainly be a reason.”

    Actually, in principle I don’t disagree with you the role psychiatry should play in illness. Maybe I am just letting my experience get in the way.

    I hope I’m just an individual case, when I was treated for depression, I also complained of sleep problem, intense fatigue and was undergoing treatment and PT for chronic cases of muscle, tendon pain and mentioned vertigo spells a couple times to my GP and Psychiatrist. Over six or eight years doctors did two thyroid TSH tests which showed “normal”. No one suggested pursuing a positive antinuclear anti-body test after lupus was ruled out. No one checked my neck for inflammation. After a number of years, I felt a pressure in my neck, thyroid nodules were found and I was prescribed Synthroid. My fatigue and muscle symptoms dramatically improved. My vertigo spells disappeared.

    I don’t know if what was going on was a lack of craftsmanship, or if that’s how SBM medicine is supposed to work (it just takes 6-8 years for thyroid disease to develop to the point were it’s severe enough to be recognize by medicine) or if Sythroid was just the world’s best placebo for me.

    But, damn, it’s hard to hear all this stuff about how medicine works, when in your experience, it doesn’t work that way.

    But, the bright side is, I can now tell folks, for muscle spasms that make you want to lie on the floor and cry, light exercise is a bit helpful. I did not learn this from my doctor, but I read it on a fibromyalgia self-help site. It’s supposed to be something about increasing blood flow to the affected muscles. So it’s not surprising to me that Tai Chi might provide some relief. I would question how much it actually provides over any other activity that increases blood flow to the muscles. I’m not sure if stretching (from control) would do that.

  33. geo says:

    @ wertys: re “I think yiou learn a lot about someone from looking at which set of irrational medical beliefs they fall for !”

    There does seem to be a worrying preference amongst some for presuming any medical condition of unknown cause should be treated as if it were related to the patient’s personality, behaviour or beliefs. We all like to blame the victim for their own misfortune, but it is dangerous to allow this bias to affect the way we treat others.

    A couple of evilrobotxoxo’s comments stood out to me:

    “All patients seen by any competent psychiatrist see get full metabolic and medical workups if there’s any possibility that non-brain-related medical causes could be contributing.”

    The leading psychiatric CFS researchers have long argued that extensive medical testing for CFS patients should be avoided, as it is likely that some abnormalities will be found, and this will only encourage the detrimental sickness beliefs of the patient.

    I don’t know where the current work on MRV’s and CFS will lead, but hopefully it will act as a reminded as to just how limited our current testing is. Treating patients as if they are psychologically disturbed based only on an inability to find a current physical cause can have a serious and damaging impact on them and the way they are treated by others.

    “As a psychiatrist, I can tell you that there is high comorbidity between somatizing/psychogenic pain syndromes and cluster B personality traits. I don’t know what the numbers are, but the relationship is pretty obvious to anyone who works in medicine.”

    I find this a bit worrying. If those working in medicine are having to deal with patients who are suffering from an illness of unknown cause and little can be done to help them I expect it will be tempting to see their pain as exaggerated and melodramatic. Their emotional problems the result of innate aspects of their personality rather than the hardships they are having to endure. Their dissatisfaction with the treatment they receive as unreasonable and a reflection of their own self-obsession. So on and so on.

    One of the problems with a willingness to so casually discard the presumption in favour of mutual mental health is that it makes it very easy to discredit and marginalise the claims of those who are weak and in need.

  34. evilrobotxoxo says:

    Michele,

    I’m sorry to hear that it took them so long to figure it out, but I’m glad they eventually did. TFTs are a funny thing because there are people with ostensibly normal values in the high and low ranges who really are symptomatic, and there is evidence that synthroid can be beneficial in depression even in people who have normal TFTs. It’s certainly true that conditions often get diagnosed only after their severity reaches a certain point, and it’s unfortunate that it works that way. Medicine is a highly imperfect thing, and I would be among the last to argue that we’re doing a good job, only that we’re doing a better job than other medical practices not grounded in science. Again, I’m glad they eventually figured it out.

  35. evilrobotxoxo says:

    @geo

    I agree with a lot of what you’re saying about stigmatization of patients with difficult to treat disorders. And I’m not disputing that people with “medical” problems can be misdiagnosed with psychiatric conditions due to frustrating by the treating physician. I once saw a patient get diagnosed with a psychogenic pain syndrome, by an orthopedist, while recovering after getting hit by a car!

    However, I think you have a false underlying premise, which is that “psychological” conditions and “medical” conditions are somehow different. They are not. The brain is a physical system, subject to the same rules as any other physical system. Personality structure, pain tolerance, somatization, etc. are aspects of the physiology of the nervous system. You seem to believe that somatization disorders do not have a physical cause, but no one who knows what they’re talking about claims that this is the case. The claim is simply that the cause lies within the nervous system.

    I want to point out that I do not think that fibromyalgia, CFS, etc. are all somatization disorders. I’m not convinced that any of them actually represent monolithic clinical entities, as opposed to constellations of symptoms with multiple underlying etiologies.

    Let me put it this way: somatization and conversion disorders exist. That is beyond question. Assuming, for the sake of argument, that fibromyalgia, CFS, etc. are conditions with “medical” etiologies, do you think it’s possible that people with psychiatric conditions could receive inappropriate diagnoses of fibromyalgia, CFS, etc? What percentage of people carrying these diagnoses do you think it would be? How would you propose that a physician distinguish between these different populations? If these populations can’t be distinguished reliably, should psychiatric treatment be withheld from the entire population to avoid stigmatization?

  36. geo says:

    @ evilrobotxoxo:

    “However, I think you have a false underlying premise, which is that “psychological” conditions and “medical” conditions are somehow different. They are not.”

    I think I’d disagree here (although I’d use ‘physical’ rather than ‘medical’). Certainly, there can be no clear distinction – our minds result from the operation of our brains: physical trauma can affect the workings of our minds, and the working of our minds can affect the operation of our bodies. But I still think that we can meaningfully group together psychological and physical conditions, and that they are somehow different – even if the boundary is not always as clear and easy to recognise as some seem to believe.

    I’m not sure if you are doing this, but I have noticed a tendency for psychologists to take unusual positions on notions of personal accountability, free will and moral responsibility: as if someone whose brain chemistry is such that they are driven to rape children should be no more hated than someone who has got liver cancer. If you are having to spend your working day helping paedophiles, this could be a useful belief to hold, but it is not a view of morality that is widely accepted or convincingly argued for and if you believe otherwise it could lead you astray.

    “If these populations can’t be distinguished reliably, should psychiatric treatment be withheld from the entire population to avoid stigmatization?”

    This is the only one of your questions I feel I can give a meaningful answer too.

    I’m certainly not arguing that psychiatric treatment should be withheld from those patients who request it, or that if there is evidence of unreasonable beliefs that this should not be addressed, but instead that the presumption that those suffering from a medically unexplained conditions are psychologically ill is unreasonable and often damaging.

    It is not surprising that this approach has led to many with FMS, CFS, etc becoming instinctively hostile to psychological interventions. Even those whose illness may be primarily psychological are likely to realise that it is unreasonable to assume this to be the case from the get go, and so such an approach can, and has, undermine the trust and respect that would be needed to overcome such difficulties.

    This could just be a reflection of my own biases, but it often seems to me that even when there are good pragmatic reasons for behaving unreasonably in the sort-term, it will come back to cause trouble later on.

    PS: In case anyone is interested, the quacky quotes I provided in my first reply are actually from Wallace Sampson’s writings here on SBM. He is the contributor who has covered these issues most regularly, and works well as an example of the sort of quackery that will drive many patients away from mainstream medicine.

  37. evilrobotxoxo says:

    @geo:

    This has been interesting, too interesting in fact, preventing me from getting my work done, so unfortunately this will have to be my last post.

    “I’m not sure if you are doing this, but I have noticed a tendency for psychologists to take unusual positions on notions of personal accountability, free will and moral responsibility: as if someone whose brain chemistry is such that they are driven to rape children should be no more hated than someone who has got liver cancer.”

    I’m a psychiatrist, not a psychologist, but I would say this: replace “rape children” with “engage in same-sex relations” and ask people in 1950 what they would say. You’re opening up a whole huge can of worms, and unfortunately I DEFINITELY don’t have time for the whole free will discussion. However, your statement is telling, and I think it really gets at the heart of our disagreement.

    The fact that some people are given what you call “psychological” diagnoses for “physical” problems obviously raises some strong emotions in you. I’d bet that if someone was given a diagnosis of peripheral neuropathy, you wouldn’t be angered by the idea that the diagnosis is inappropriate because it could be an undiscovered rheumatological disorder causing peripheral nerve irritation. The reason why it bothers you that someone would be given a “psychological” diagnosis is precisely because of the moral standpoint that you’re espousing above. This standpoint says that people with “psychological” conditions are weak of character. Fat people are lazy. Alcoholics are weak-willed. Depressed people should just snap out of it. To answer your question, I do think this kind of moralizing is not only factually incorrect, but more importantly, harmful to the patient. It takes legitimate medical conditions beyond the person’s control and turns them into shameful moral failings, and it’s one of the biggest hurdles to getting people the help they need. You say that giving a psychiatric diagnosis is “blam[ing] the victim for their own misfortune.” In fact, it is moralistic misunderstanding of these physical disorders of the nervous system that stigmatizes them.

    Finally, there is no proof that any psychiatric disorder is not simply a secondary manifestation of some undiscovered metabolic or infectious etiology. It’s very difficult to prove a negative. If one applied your argument to all mental health conditions, the end result would basically be a form of mental illness denialism.

  38. geo says:

    @ evilrobotxoxo:

    Pleased to hear you don’t have time for a discussion on free will. I’ve had a few with psychiatrists now, and it sounds like we could have ended up re-treading that ground.

    You said: “You say that giving a psychiatric diagnosis is “blam[ing] the victim for their own misfortune.” In fact, it is moralistic misunderstanding of these physical disorders of the nervous system that stigmatizes them.”

    Where as what I actually said was:

    “There does seem to be a worrying preference amongst some for presuming any medical condition of unknown cause should be treated as if it were related to the patient’s personality, behaviour or beliefs. We all like to blame the victim for their own misfortune, but it is dangerous to allow this bias to affect the way we treat others.”

    Surely you acknowledge that people do tend to hold people accountable for their own personality, behaviour or beliefs in a way which is not the case for whether they go bald or not.

    Giving a psychiatric diagnosis need not be motivated by a desire to blame the victim. It could well be based upon a reasonable assessment of the available evidence, having given due weight to the potential damage than could be done by misdiagnosis.

    You said:

    “Finally, there is no proof that any psychiatric disorder is not simply a secondary manifestation of some undiscovered metabolic or infectious etiology. It’s very difficult to prove a negative. If one applied your argument to all mental health conditions, the end result would basically be a form of mental illness denialism.”

    This is wrong. It could well be that someone becomes more aggressive following a viral infection that has resulted in some neurological alteration. They did not choose to have this infection, but still it would be fair to blame them for their aggressive behaviour and hold them accountable for it. Just because their mental instability was brought about by viral infection does not allow us to absolve them of their personal moral responsibilities any more than the abuses paedophiles have often suffered as children permits them to avoid blame for their own actions. This is not any sort of denialism. It’s a conception of free-will and personal responsibility which can seem bleak to those which have grown up with a dualistic view of consciousness but it’s massively superior to the version you have put foreword:

    “replace “rape children” with “engage in same-sex relations” and ask people in 1950 what they would say. You’re opening up a whole huge can of worms”

    The tightening of my stomach serves as a timely illustration as to how emotional reactions can manifest in somatic sensations. There are significant and real moral differences between those adults who choose to engage in same-sex relationships and those who choose to rape children and you cannot simply replace one for the other within that sentence without fundamentally altering the argument being put foreword. That you seem not to recognise this, or think it is not important, serves as a demonstration as to what the sort of rejection of harmful-to-the-patient-moralizing leads to. How very non-judgemental of you.

    I think this is really the heart of our disagreement. I think it is important to try to behave in a moral and reasonable manner towards other people. I get angry when I see people putting foreword poorly thought through arguments which can harm patients. I get angry at the idea of people being treated unreasonably because of this. I do think that people should be held accountable for the way they behave, what they do, and what they think. It is not just that I am concerned about the damage that can be done by prematurely treating patients as if they were psychologically ill – I am angered by any and all mistreatment of individuals: the cavalier manner in which some are willing to claim that others should be treated as if they were psychologically ill is a particular bug-bear at the moment, especially as it seems so readily accepted by many who would normally consider themselves to be rationalists. Indeed, some seem to see it as part and parcel of a materialistic conception of consciousness. This is wrong, and greatly troubles me. Even those who recognise that this is an unreasonable approach to medicine still seem keen to make excuses for their colleagues – maybe they’re just trying to be non-judgmental about it? How sickening.

    It’s probably the quality of argument put forward by people like Dr Sampson which angers me the most though. Stupidity always ends up damaging people, and we should all be angered by it – even if his quackery is merely the result of some nasty bacteria eating his brain.

  39. trrll says:

    @geo

    “It could well be that someone becomes more aggressive following a viral infection that has resulted in some neurological alteration. They did not choose to have this infection, but still it would be fair to blame them for their aggressive behaviour and hold them accountable for it.”

    On a science-based forum, concepts such as “blame” may not be entirely appropriate.

    If we reject dualism, then we must conclude that a person’s behavior is determined by their genetic makeup, their environment and history, plus some degree of random “noise” in their nervous system.

    So in one sense, we can assert that it is not “fair” to blame somebody for engaging in [insert reprehensible behavior of your choice], because none of these determinants are under the control of the individual–indeed, there is no separate free-willed entity to take control.

    But…

    If we are viewing human behavior solely in terms of stimulus-response, then we also have to consider how our behavior toward them influences their behavior, because that is part of those environmental influences.

    In other words, whether or not it is “fair” to blame them, it remains possible that our acting as though we hold them responsible and regard them as capable of choosing to modify their behavior will in fact reduce their propensity to engage in [reprehensible activity]. Or to put it another way, it is possible that our emotional responses to certain types of behavior have evolved because in fact they are effective in modifying the behavior of others. These are of course behavioral hypotheses that are amenable to experimental testing.

    For example, in the ultimatum game, people have been reported to behave more fairly when they believe that they are playing with another person, who is capable of blaming them for behaving unfairly, than when they believe that they are playing the game with a computer.

  40. geo says:

    @trrll:

    blamed, blam•ing, blames
    1. To hold responsible.
    2. To find fault with; censure.
    3. To place responsibility for (something):

    This is not an appropriate concept for a science based forum?

    “If we reject dualism, then we must conclude that a person’s behavior is determined by their genetic makeup, their environment and history, plus some degree of random “noise” in their nervous system.

    “So in one sense, we can assert that it is not “fair” to blame somebody for engaging in [insert reprehensible behavior of your choice], because none of these determinants are under the control of the individual–indeed, there is no separate free-willed entity to take control.”

    If we embrace dualism and assume a person’s behaviour is determined by their genetic make-up, environment and history, some degree of random noise and the magical influence of their soul, why would it be any more fair (no scare quotes) to blame them for raping children?

    Why would having a soul give us any more control over ourselves?

    Yet your belief is widely held. To me, it seems likely to be a hang-up from people who have grown up with a dualist understanding of consciousness and morality and then, as they’ve learnt more about the way our minds work they assumed that rejecting dualism required a whole-sale rejection of notions of personal responsibility too. It’s like when people learn about how our eyes interact with our brains, light and the outside world and then conclude: “There is no true colour! That ball is not really red, it just appears that way to us.” The ball is really red: if it reflects light in a manner which is commonly perceived by humans to be red, that is all that is needed to be ‘really red’. You can’t get redder. There’s no magic red, which would be perceived in the same way regardless of the biology of the creature viewing it. Equally, we do not need magic souls operating outside of the normal laws of physics in order to be responsible for our actions.

    Indeed I think that your notions of morality are dependant on dualism, even as you reject it eg: “there is no separate free-willed entity to take control.” How could there be? Why would there being such a phenomenon allow us to then talk about blame?

    We are our brains – it makes no sense to say: “Don’t blame me, it was just my brain that did it” or “I can’t be held responsible because I’m not a magic soul – I’m a chemical brain.”

    That a rejection of personal responsibility is sometimes seen as the de facto science-based approach is a terrifying misunderstanding of the moral implications of our developing understanding of the brain. Indeed, this is not a new idea. Recent advances in brain scanning technology are letting us peer ever closer into the chemical concoction of our minds, but moral philosophy has been engaging with the implications of determinism for millennium. Claiming that it requires the abandonment of moral judgements seems to primarily be a cheap piece of straw-manning by those opposed to materialist or determinist conceptions of reality rather than being presented as a serious argument by those promoting such a view. That some now want to make it a necessary part of a scientific understanding of reality is deeply worrying.

  41. trrll says:

    geo

    “That a rejection of personal responsibility is sometimes seen as the de facto science-based approach is a terrifying misunderstanding of the moral implications of our developing understanding of the brain.”

    Except, of course, that that is pretty much the opposite of what I was saying. Rather than rejecting personal responsibility, I am suggesting that treating other individuals as personally responsible for their actions and choices likely yields the best behavioral outcome, and represents the emotional correlate for human behavior patterns that have evolved to enable us to negotiate cooperation with one another.

    And that this applies even if it is true that human behavior is entirely determined by genetic makeup, environmental influences, and neural random factors.

  42. Charon says:

    the tai chi group from 62.9±15.5 to 35.1±18.8, with an improvement in the control group from 68.0±11 to 58.6±17.6, with a highly statistically significant p-value.

    I’m not familiar with the conventions for presenting statistical values in medicine. In my field (astrophysics) the ± would be 1 sigma, which would mean the difference between final control and final treatment (58.6-35.1=23.5) is less than the 1-sigma error (sqrt(17.6^2+18.8^2)=25.8). I.e., the result isn’t significant at the 1-sigma level, i.e. there is no difference (my field uses 3-sigma as the standard for statistical significance, although I’m aware biology/medicine often uses 2-sigma).

    So… how is this “highly statistically significant”? I know I’m assuming simple Gaussian distributions, but that should be an okay approximation.

  43. geo says:

    @trrll:

    I quite understand, and agree, that you can make that sort of pragmatic argument, but I was replying to your belief that: “On a science-based forum, concepts such as “blame” may not be entirely appropriate.”

    I do not think that there is anything unscientific about blame even if human behavior is entirely determined by genetic makeup, environmental influences, and neural random factors.

  44. geo says:

    @trrll: I think I must have deleted a sentence in my first reply to you that made it clear I agreed with the second half of your comment, but was disagreeing with the first half. I think it was getting too long by that point. Sorry for not being clear about that.

  45. evilrobotxoxo – Thanks for taking the time to respond and clarify. Just to be clear, I did not mean to imply that medicine not grounded in science is better. In fact, since I have a friend in the CAM/supplement business, I did have plenty of opportunity to follow that route, but never saw the sense in it then, and I don’t see that anything my friend recommended could have helped, and some of the hormone type stuff she seemed interested in didn’t sound like a good idea to me.

    I wanted only to say that from a patients perspective, things are not as cut and dry as they seem when folks read articles on particular diseases, or when doctors use term like ‘full metabolic and medical workup’. And, well urgh, it’s quite hard to explain. Maybe it will all come to me in another thread, so I’ll leave it there for now.

  46. geo “I do not think that there is anything unscientific about blame even if human behavior is entirely determined by genetic makeup, environmental influences, and neural random factors.”

    hmm, since blame generally is to do with actions that are right or wrong, (ethically or morally, not factually) and science is to do with provable elements, then I do see a disconnect.

    Science can inform ethics, but it can not prove that one ethical approach is “better” than another or that one ethical transgression is “worse” than another. It could possible show that one approach is more likely to meet a prescribed goal.

    Of course there’s no reason science can’t examine ethics. All sorts of interesting stuff there, I’m sure.

  47. stewiegriffin81 says:

    @ Charon

    They found the statistical significance by using the two sample t test. This means that the difference between the two samples in FIQ changes is divided by the square root of (sample one’s variance squared divided by sample one’s sample size + sample two’s variance squared divided by sample two’s sample size).

    This gives a test statistic of 4.1 that can then give a p value after determining the degrees of freedom (which in this case should be 64, I believe). Thus, the p value of a two sided t test in this case will be about 0.0001, which is consistent with the published value here of <0.001

  48. geo says:

    @ micheleinmichigan:

    Just because science cannot be used to prove what is morally right and wrong does not mean that there need by any disconnect between science and moral reasoning.

    Science is a useful part of our attempt to develop a rational, evidence based understanding of the world. It should not be segregated from all other aspects of this endeavor, indeed, I do not think that it can be.

  49. geo – yup, that’s pretty much what I was saying. Perhaps ‘disconnect’ wasn’t the best word choice.

    The reason that one must make it clear that science can not prove a moral right or wrong is due to the fact that people are constantly trying to do just that. I find it useful to be wary of that. That is what I meant by ‘disconnect’.

  50. geo – you appear to be continuing an argument with some psychologist or psychiatrist that you talked to once. But I do not see anywhere on the board, or even this site, where “people” are making any of the claims about the brain and/or blame that you are claiming.

    One can present arguments for blaming or not blaming an anorexic for not eating or an alcoholic for drinking, but when it comes down to trying to help that person, a doctor should just look at all the evidence available to find the most likely therapies to overcome the disease. If you don’t have enough evidence, you fund research to find it (or hope that someone does).

    So, if you have evidence that “blaming” helps or hinders in the treatment of a certain disease, well okay then. But if it’s just a question of whether someone “should” blame another for their condition, that doesn’t seem like medicine. That’s another field.

  51. geo says:

    @micheleinmichigan:

    I’m not sure what specific claims I have made about claims made by others here that you think are inaccurate. If you provided a quote, I could have a look.

    A few of my comments were explicitly targeted at the type of arguments I have heard from others rather than just the comments made here. It can sometimes be difficult to know exactly what some people mean, which is why I sometimes allowed myself to be guided by past discussions and add comments like “I’m not sure if you are doing this, but I have noticed a tendency for psychologists to…”. I’ve also tried to address the specific comments made by people here as well, quoting the parts I was focusing upon.

    I think that to try to detach moral arguments from medicine and instead follow a purely pragmatic approach towards treating patients is to embrace an intentional type of ignorance, and that in the long run this will lead to distortions of thought and behaviour which will harm patients. Life cannot be so neatly divided into separate fields.

    While I believe that you can develop a purely pragmatic foundation to morality, as trrll tried to do, such attempts often become self defeating as moral arguments founded only in pragmatism rather than an honest pursuit of truth often lead to rather unsatisfactory results in pragmatic terms.

    Medicine should always be driven by morality and the sense that there are certain ways you should treat patients. We cannot detach medicine from questions about what moral judgments we “should” make, just as we cannot detach any other human endeavor.

  52. GinaPera says:

    @Troll, or is it trrll.

    “nutritional woo,” is it?

    Thank you for summarizing the problem some people have with your brand of “science-based medicine.” It’s not based in biochemistry.

    Again, the “discourse” among many of these comments make me feel as if I’m at a convention of those high on the autistic spectrum.

    No offense to people with autism. We often benefit from those whose knowledge is deep but narrow.

    But the inability to make connections, the inability to synthesize information, the inability to make leaps from one set of information to the next, that is the dark side of those high on the autistic spectrum.

    Also, to talk in many abstractions that rarely address real-life people’s issues. Not to mention the utter lack of compassion and often obsessive need to be “right.”

    I’d match Dr. Edelberg against anyone here who fails to understand what’s required to help people with their bucket diagnosis of fibromyalgia — and fails to show the least bit of intellectual curiosity about it. It’s embarrassing on an alleged “medical” forum and only one reason why our healthcare system is so very sick.

  53. GinaPera says:

    @EvilRobot — well said on this point:

    “Finally, there is no proof that any psychiatric disorder is not simply a secondary manifestation of some undiscovered metabolic or infectious etiology. It’s very difficult to prove a negative. If one applied your argument to all mental health conditions, the end result would basically be a form of mental illness denialism.”

    As for your other point, the trouble with many “psychiatric” diagnoses is that many psychiatrists fail to understand “metabolic or infectious etiology” and are still fancying themselves psychoanalytic Sherlock Holmes because, well, it’s so much more entertaining, apparently.

    Yes, this attitude has changed in recent years. But judging from the average presentation at last year’s APA conference in SF, it’s not changed nearly enough.

  54. evilrobotxoxo says:

    @geo:

    The only reason I’m posting again is because it’s clear that there were a couple of miscommunications, partly due to lack of specificity on my part. I’m sure we’ll end up disagreeing anyway, but I want us to be clear on what we’re disagreeing about.

    “Finally, there is no proof that any psychiatric disorder is not simply a secondary manifestation of some undiscovered metabolic or infectious etiology. It’s very difficult to prove a negative. If one applied your argument to all mental health conditions, the end result would basically be a form of mental illness denialism.”

    You responded to this as though I were referring to your moral argument, but I actually meant for this to refer to your other argument, that it’s unjustified making a psychiatric diagnosis when unidentified “medical” causes could be the underlying factor. What I’m saying above has nothing to do with the moral aspect of anything, simply the factual aspect of whether a given disease is a process localized to the nervous system vs. outside the nervous system.

    “replace “rape children” with “engage in same-sex relations” and ask people in 1950 what they would say.”

    I apologize for not spelling my meaning out more explicitly with this, as it seems that what you thought I was trying to say is exactly the opposite of what I intended to say. It occurred to me that I should be more explicit at the time, but I was in a hurry. What I meant is that raping children is completely morally abhorrent, at least to me, while consensual adult same-sex relations are morally fine (though there is a vocal but rapidly-shrinking subset of the population who disagrees with that). People like you and me, in the year 2010, agree that these things are totally different. But the vast majority of people in 1950 felt that these two things were a lot more similar. Homosexuality was taken to be the sign of a terrible moral perversion, an unholy “choice” to engage in deviant behavior. And I’d be willing to bet that there were times and places in human history where consensual adult homosexual relations were even considered morally worse than “consensual” relations with an opposite-sex child. And, of course, there was ancient Greece, in which pederasty was just fine.

    My point is that morality is not a scientific concept, and to some extent it is fundamentally based on a (scientifically inaccurate) premise of dualism, which is why it is difficult to reconcile with concepts that actually are scientific, such as modern understanding of the brain. This is not to say that we shouldn’t have morality, only that we should acknowledge that there isn’t any neat way to square it with reality.

    I actually reject the validity of bringing morality into this discussion at all. With a few notable exceptions, people don’t choose to be sick or be in pain. If you’re having hallucinations because you’re schizophrenic or because you’re delirious from an infection, there is no moral difference, but physicians need to make an accurate diagnosis to guide the treatment. A diagnosis of schizophrenia is not blaming the patient. If someone is going to stigmatize one but not the other, that’s unfortunate, but ultimately it’s their problem. Similarly, with things like chronic pain syndromes, we have to try our best to make an accurate diagnosis. Some of the less enlightened among us will always view referral to a psychiatrist as a moral judgment meaning that the person is crazy or weak, or that their illness is somehow their fault. This is not the case. It’s sad that people think of it that way, but the solution to the problem is to educate people and remove stigma, not to deny that psychiatric conditions exist or to avoid giving psychiatric diagnoses to patients when it is appropriate.

  55. geo – there is a difference between treating a patient ethically and judging them morally. IMO the former is required, the later is a distraction from the primary purpose of the doctor patient relationship, which is to help the patient.*

    It seems that we will not see eye to eye on this one, so I will bow out.

    *There is a second important requirement for a doctor, which is public safety. There are laws and medical ethics guideline that deal with the dilemma a doctor faces when a conflict between being helpful to the patient and public safety arise. I believe a doctor should follow the law and/or ethical guidelines in that case.

  56. pmoran says:

    GinaPera, you have been a bit savage with us. Yet how do you know that Dr Edelberg is not merely using the veneer of “holism” to get under the guard of patients who don’t want to look at some aspects of their condition?

    He says this—

    Quote–

    “If you have fibro, philosophically understanding what’s occurring in your body is an essential part of treatment. Once you pull back and see the larger fibro picture, you’ll realize that all your life you (and likely your mom) have been more susceptible to stress and more sensitive to physical sensation, like pain, than other people.

    You’ll come to see that fibro is not a disease but a defense (Freud’s pupil Wilhelm Reich called it “character armoring”) and you’ll recognize that it won’t develop into a disease but will remain what it is–a stress response from hell–until you understand the message of this pain.

    Your fibro appeared as a response to stressful factors in your life. ”

    Unquote

    How is this so different from the views you profess to despise?

    Understand me — I believe there is a mixture of things going on. The basic symptoms of fibromyalgia are undoubtedly real and they are quite prevalent in supposedly healthy young populations, those who don’t regard themselves as being sick. The illness may often be merely an exaggeration of these for various reasons.

    Others will eventually prove to have an ordinary, undiagnosed medical condition, so doctors have to remain alert.

  57. GP “But the inability to make connections, the inability to synthesize information, the inability to make leaps from one set of information to the next, that is the dark side of those high on the autistic spectrum.

    Also, to talk in many abstractions that rarely address real-life people’s issues. Not to mention the utter lack of compassion and often obsessive need to be “right.”

    So what’s the description for a person who is unable to understand that a diagnoses of autism or any other developmental or psychiatric disorder can not be made via a comment box on the internet? Also, that any such diagnoses which is made in order to discredit the unwilling “patient” or to make your point at their expense…. Please, let’s talk about lacking subtlety or the obsessive need to be “right”.

    Kettle, let me introduce you to the pot.

    How about you just argue you points with logic, facts or even anecdotes and not use other people’s struggles or diagnoses’ to score points?

  58. geo says:

    @evilrobotxoxo:

    Good to try to disagree with what each other actually believes.

    I think that one of the reasons I misunderstood your first point is that you had misunderstood the argument you were replying to.

    “I actually meant for this to refer to your other argument, that it’s unjustified making a psychiatric diagnosis when unidentified “medical” causes could be the underlying factor.”

    That’s not what I have argued for.

    If someone believes that they have had an undetectable chip planted in their mind which feeds them messages from a Chinese military camp committed to trying to make them kill their upstairs neighbour, they could be right. Right now it’s pretty darn unlikely, but technology is progressing all the time, and who knows what those military tech boys have come up with.

    I am not arguing that every alternative possibility must be ruled out with certainty before any psychiatric diagnosis is applied, but rather that the casual assumption of psychiatric causes which many, like Wallace Sampson, make for conditions like FMS is immoral quackery.

    We should not avoid psychiatric diagnoses when they are appropriate, but think it needs to be recognised that there are additional burdens caused by a psychiatric diagnosis, and that they require that psychiatric diagnoses be made more cautiously than were this not the case.

    I also think it’s important that we recognise how our own biases will affect our judgements of others, especially when they face long-term hardships. It’s far too easy for those with positions of authority over weaker members of society to develop justifications for their own relative good fortune. This needs to be constantly fought against.

    It needs to be acknowledged that to make the claim that someone’s perceptions of reality are so deeply misguided that it has served to disable them brings with it a number of consequences quite different to those of a non-psychiatric diagnosis. Removing a patient’s ability to trust in the operation of their own mind, removing societies presumption of reasonableness to a citizen – these are morally significant matters that some seem keen to ignore in order to avoid making their job more complicated and stressful than they would like.

    You wrote: “If someone is going to stigmatize one but not the other, that’s unfortunate, but ultimately it’s their problem.” No. It is also the patient’s problem, and that should be accounted for if you are interested in treating them fairly. To deny this form of suffering, which can be inflicted onto a patient because of your actions, is to fail in your responsibility to your patients. That is not to say that we should be slaves to the prejudices of others, but we do need to acknowledge that giving a ‘best guess’ diagnosis of a psychiatric disorder to patients when there is no clear evidence either way can have serious and damaging consequences for them.

    Re: Raping children

    I had assumed that you were making this point, and that you were not as revolted by homosexuality as child rape; but that you thought my argument could work were the two substituted is what troubled me. Here’s another example:

    “What I meant is that raping children is completely morally abhorrent, at least to me”

    Thank you for adding ‘at least to me’. Otherwise I could have thought you were naively suggesting that raping children would be morally unacceptable in any social or historical context… That there was something innate to the nature of children that meant we could say that to rape one for you own sexual pleasure would always be wrong. We can use the methods of science to measure the physical damage done to a child’s anus, to study the way in which such trauma can alter the development of their brains, and the differing behavioural propensities that result – but to say raping children is morally abhorrent without adding any proviso, what a simplistic embrace of dualism that would require, eh?

    As you said:

    “This is not to say that we shouldn’t have morality, only that we should acknowledge that there isn’t any neat way to square it with reality.

    “I actually reject the validity of bringing morality into this discussion at all.”

    It seems to me that this is the key problem here. I think that morality needs to be a part of all human activity and that there is no particular tension between morality and science. Currently there is no way to square reality with reality. Our scientific understanding of the universe has yet to slip into a neatly unified whole, but it’s been a very long time since we expected it to do so. Perhaps you are expecting an unrealistic neatness or simplicity and this is what is really causing you trouble?

    @ micheleinmichigan:

    I do not think that a doctor patient relationship can be so neatly detached from the rest of reality. Medicine is full of moral decisions, and the views of doctors can be vital in deciding how these decisions are taken. To have doctors believe they need to spend their working lives disengaged from a range of important moral questions will inevitably affect the workings of their minds, and go on to impact other aspects of their social interactions.

    I have said that this could be a reflection of my own biases, but it really does seem that unreasonable behaviour, even when seemingly justified by short-term pragmatic considerations, seems to come back to cause trouble.

    I’m not saying that doctors should start having their actions driven by whether they approve of their patients or not, but I do think we need to reject this presumption that there is a conflict between behaving scientifically and making moral judgements.

    I’m really just repeating what I’ve already said though.

  59. Geo – All I can say is if a doctor feels that the need to offer the most effective treatment available to a patient is a burden to their moral code, then perhaps they should not be a doctor. If their moral code supports the most effective treatment available, there is no conflict.

    I really don’t see the need for all the smoke and mirrors, I abide by morals or ethics that have pragmatic reasons (long term or short term), I discard those that I see no pragmatic reason for.

    What is the use of a moral that has no purpose?

  60. GinaPera says:

    @EvilRobot—-

    I must tell you, I’m VERY aware how many psychiatrists treat their patients, perhaps more aware than you are. I’ve heard the stories every day for 10 years. And it is scandalous.

    Some do all those things you suggest — the metabolic panels, folate, etc. — and actually don’t need to rely on the lab report to tell them what’s what. But that’s the rare few. And they have my utmost respect and gratitude for the extra care and intelligence they bring to a very demanding job.

    When it comes to ADHD, at least — hardly the “simple” disorder that too many psychiatrists believe it is — I credit the rest of the profession with the huge anti-medication backlash we’re experiencing now. It’s a national tragedy.

    Psychiatry: Another specialty where once-willing patients have been scared away from “science-based medicine” by haphazard and downright reckless clinical standards. No wonder they seek the “woo.”

  61. geo says:

    @ micheleinmichigan:

    “What is the use of a moral that has no purpose?”

    What is the use of any belief that has no pragmatic benefit? If believing that we are evolved creatures rather than divinely created will only serve to mean you behave in a less altruistic and moral manner, why not embrace creationism? The trouble with these sorts of pragmatic arguments is that they often seem self-defeating on their own terms. It is very difficult to discern which beliefs will have negative or positive beliefs – seemingly even more difficult than trying to decide which beliefs are most likely to be true and more open to distortion according to our own preferences and biases. Despite the massive burden of trying to decide which beliefs are likely to have the optimal impact in pragmatic terms, it very often seems that those who try to justify their own beliefs in pragmatic terms are not frantically thinking through the varied implications of their possible beliefs, but instead are merely trying to legitimise an intellectual laziness or self-interested deception.

    I’ll go for a simplified example related to the discussion. Lets say that those medical staff who work with drug users find it pragmatically useful to view the decision to take drugs as being something their patients cannot be held morally accountable for. How will this affect the way their views are assessed by politicians who need to deciding funding and policy decisions for their drug policy? The police will have opposing pragmatic considerations, it being more helpful for them to emphasise the moral necessity of holding drug addicts accountable for their decisions and the harm they cause. Will these short-term pragmatic considerations lead to problems and conflict in the development of long-run drug policies? Maybe it will be to the benefit of a reasonable and well thought through approach towards drug use, but my instinctive belief is that it is better to encourage people to think honestly and clearly about these matters rather than allow their beliefs to be guided by short-term pragmatic considerations.

  62. Fifi says:

    Tai Chi isn’t that different than yoga in many ways, it’s a meditative form of exercise that’s very much about body/self awareness. Meditation has already been shown to be useful in pain management, it’s not surprising that forms of moving meditation are also useful for at least some people. The difference between Tai Chi and yoga and other forms of exercise is the type of concentration being taught – tai chi and yoga teach relaxed concentration (and a meditative state – there is an intensity of concentration but it’s unstressed, there’s no urgency), when we’re being highly competitive or concentrated in a way that forces our body beyond limits there’s a high level of stress involved. They’re both forms of concentration, and some people either naturally or through practice can bring the relaxed form to contexts where many people apply the stressed, more survival/competitive form of concentration. It’s just that practices like tai chi and yoga are actually designed to promote relaxed concentration. Though, of course, highly-driven perfectionistic people and certain personality types can turn even meditation into a competitive sport.

  63. geo – you did not answer my (not rhetorical) question. What is the use of a moral code that has no purpose?

  64. also geo – Just to reinterrate, I have never suggested short term pragmatic consideration. Just because something is pragmatic or purposeful, does not make it short term or short sighted.

    For instance, my purpose may be to live in a world without violence. Why is that a purpose? I don’t like being hurt and my empathy for others causes me to feel pain when I see others hurt (vastly simplified). If that is my goal, how does that guide my actions? Is there a possibility that I can use that goal to rationalize an action that is morally wrong? Sure, human’s are good at rationalizing. But I don’t see that the possiblity of rationalization is any greater than when following a moral that is prescribed to me by some religion or philosopher that has no coherent meaning or purpose to me.

    But, maybe I should just go out a burn a few witches, because someone once said it was the right thing to do?

    I would suggest that your comments show that your morals do have a purpose, you are just not thinking about it in those terms.

  65. geo says:

    @micheleinmichigan:

    I quite understand that it is I who has emphasised the short term nature of our pragmatic considerations, but I think that the difficulty of understanding the long term consequences of our decisions is a serious problem for anyone who wants to claim that they decide upon their moral positions pragmatically.

    I’m not arguing that you should follow absurd religious myths, of incoherent moral philosophies, but that you should address moral questions with the same commitment to reasonably trying to find what is most likely to be true that you would make to other questions.

    I think that the moral example you provided was less closely related to our discussion than the one I had provided. I’m not sure if you are emphasising your pragmatism or your self-interest here. If you think it is acceptable to base you moral code upon self-interest then you are legitimising a lot of truly vile behaviour.

    “you did not answer my (not rhetorical) question. What is the use of a moral code that has no purpose?”

    I answered it as well as I could. I think that an honest and reasonable attempt to believe what is most likely to be true is a good in and of itself. It seems to very often also bring about the best outcomes in terms of pragmatic considerations about human happiness, freedom and development, so perhaps I am also driven by a belief that in the long run this is the best approach to take in pragmatic terms, but I’m not sure if this is the case.

    You have not answered my question, about whether you think it would be best for someone to embrace creationism if they believed that this would mean that they would lead a more virtuous life. Personally, I don’t think it’s a terribly interesting question, but if you do, it would be good to develop an answer for it.

    (I’m slightly avoiding your use of the term ‘no purpose’, because I think that honest, evidence based and reasonable moral arguments have an innate purpose, making the question rather meaningless.)

  66. “(I’m slightly avoiding your use of the term ‘no purpose’, because I think that honest, evidence based and reasonable moral arguments have an innate purpose, making the question rather meaningless.)”

    Yes, they have a purpose…see you doagree with me. :)

    As to creationism vs evolution – Sorry, I thought that was a rhetorical question to make a point. I can not think of a moral that is based on creationism, so I will forgo an example and give you an outline.

    As I see it, ethics is what happens when you have to go beyond the truth or facts, to the subjective. But, any moral or ethic that is based on a falsehood (a factual falsehood) is going to be essentially flawed. (I think you are also saying this, so again we agree.)

    I also believe that, since an ethic or moral is basically a subjective interpretation, if it is treated as a truth or fact, that is a flaw.

    If it is not subjective, then it should be provable and reproducible, just as any other objective fact, and is science, not ethics.

    This is what I meant when I said science can inform ethics.

    Not I did say that science is distint from ethics, not that it should be divorced from ethics. In order to understand and work with two different tools, one must understand their strength and weaknesses and how they differ. One can not use science and ethics interchangably, anymore than one can use a hammer and tool interchangably.

    As to whether all hell would break lose if people based their ethical actions on self-interest. I find that the people who assume that are often making the false assumption that people are psychopaths. That is not the case, human are social creature and enjoy relationships, community and the like, that is usually included in their purpose driven ethics.

  67. geo says:

    “Yes, they have a purpose…see you do agree with me.”

    Hmmm. I’m not so sure. If you see the highest purpose to be an honest pursuit of truth then we agree, but that is pragmatism only in its pragmatic rejection of pragmatism.

    “As I see it, ethics is what happens when you have to go beyond the truth or facts, to the subjective. ”

    I think that the claim that it is wrong to rape a child is true. Really true, not just a reflection of my cultural preferences. It is possible that future evidence could emerge which will show that I’m wrong (I cannot imagine what) but that is also the case for my belief that life on Earth evolved.

    “If it is not subjective, then it should be provable and reproducible, just as any other objective fact, and is science, not ethics.”

    Science is only provable once you have accepted certain premises and then chosen to engage in an honest pursuit of truth. The accuracy of the claims made by science cannot be proven to those who do not believe that a careful examination of external reality can provide evidence capable of over-turning internal instinctive beliefs.

    I don’t think that this level of subjectivity matters terribly.

    In the same way, I will not be able to provide proof that it is wrong to rape a child to someone who rejects the very notion of morality or that we have any duty of concern for the suffering of others, but once any serious and honest attempt to address this moral question is begun the evidence is so one-sided that only one conclusion can be reasonably drawn.

    Maybe you think the science is on firmer philosophical ground than I, thus making for a clearer distinction between the certain truths of science and the wishy-washy musings of moral philosophy.

    “I can not think of a moral that is based on creationism, so I will forgo an example and give you an outline.”

    You shouldn’t need to be able to think of a moral that is based on creationism. The mere fact that there are people who honestly believe that a belief in creationism means that they will behave more morally than a belief in evolution serves to illustrate what I consider to be the dangers of respecting a pragmatic approach towards truth.

    “I find that the people who assume that are often making the false assumption that people are psychopaths. That is not the case, human are social creature and enjoy relationships, community and the like, that is usually included in their purpose driven ethics.”

    I didn’t say that all hell would break loose. I said that to accept self-interest as a basis for morality would be to legitimise a lot of truly vile behaviour. Lots of these terrible things already happen, but I think that it is good to be able to condemn them in a way that is consistent with my own approach to morality. That humans are social creatures who enjoy relationships, community and the like can underpin genocide as well as compassion.

  68. Geo – Oh well, you seem very comfortable of your “truths” and your right to condemn people based on them. No need for me to interfere any further.

  69. geo says:

    How arrogant of me to think I could condemn child “rapists”.

    Anyway, I think the most important aspect of attempting to pursue moral truths is the uncomfortable clarity it can bring to one’s own moral failings. You seem to prefer believing whatever it is you think will suit you best. Maybe you should try harder?

  70. Oh, of course, you can condemn all you want. Lots of people get great pleasure out of condemning others. They feel sure in their hearts that they are correct and they know that the others are not like them.

    I don’t see what use there is in it though. You can diagnose a child rapist with a paraphilia, a personality disorder and an impulse control disorder and decide that the best place for them is behind bars. Along the way you will probably feel revolted. None of these things are incompatible with the other. The child rapist is experiencing consequences of their actions and there’s a whole team including forensic psychiatrists are trying to devise interventions to reduce the likelihood of a re-offense. I don’t see what moral condemnation adds to that beyond an enjoyable feeling of superiority.

    The child soldiers in Liberia were in a really bad spot. They were deprived of educations and many of them had done truly terrible things. Liberians could have sat around and pointed fingers at them and enjoyed feeling superior to these bad, bad, immoral child soldiers. Instead they have been working at reintegrating them into society. It’s better for the young people and it’s better for the entire society.

    I know of a church that sponsored a child rapist who had recently been released from prison. They kept an eye on him, made sure he was welcome in church, that he had jobs to do, visited him during the week, and ensured that he was never alone with a child. Their rationale was that a lonely, isolated child rapist was more likely to turn towards children than a child rapist with a supportive community of adults. Don’t know what the outcome was, but I would guess that what they did took a lot more effort than it would have to be morally repulsed and exclude him.

  71. geo says:

    Why should we put them behind bars unless we have decided that their behaviour deserves moral condemnation?

    You talk of condemnation as if it is a purely emotional response, and not the intellectual realisation that certain behaviour is wrong. Do you mention the child soldiers of Liberia because you think that the complexity and difficulty of many moral quandaries some how makes child rape more acceptable?

    Creationists also complain about scientists being smug and superior. So what? What is it about the honest pursuit of truth that seems so distastefully elitist to some?

    Dr Sampson’s writings on science-based-medicine deserve to be condemned because writing about patients in this way, without having clear evidence to support your assertions, is immoral quackery. Why bother to condemn any form of quackery unless you believe that we have a moral duty to treat one another fairly and reasonably?

    “To those who still must argue that CFS and related disorders are diseases and not somatiform illnesses, and to patients who deny their problems’ origins, allow me to drop the fomalities of physician behavior and to speak in language used here.

    “You are wrong. Stop looking for information that fits your conceptions, and try to learn what is happening to you; how your life – the only one you may have – may slip away under a pall of unhappiness and contrariness, while disallowing entry to sources that may help you the most. There is hope if defenses relent, and none if they are maintained. ”

  72. “Why should we put them behind bars unless we have decided that their behaviour deserves moral condemnation?”

    • Because they are dangerous. It keeps them away from children for a period of time and keeps them within the system for a further period of follow-up of debatable effectiveness once they are released.

    • As a deterrent of debatable effectiveness, for themselves and for others.

    • For justice to be seen to be done (yet more debatable effectiveness).

    Knowing that a person has a personality disorder, a paraphilia and impulse-control problems doesn’t make them less dangerous; it just qualifies in what ways they are dangerous and may suggest interventions that may make them less dangerous.

    Putting people behind bars is, as I have noted, of debatable effectiveness in achieving many of these goals but it’s the best we’ve come up with. When putting people behind bars is not a good solution, often the issue is that we are dealing with a problem that is larger than a criminal individual, or with behaviour that should not be criminalized in the first place. For instance, we don’t have debtor’s prisons any more* and we don’t sentence people to years of hard labour for homosexuality. Prison doesn’t enable a debtor to repay a debt or contribute to society and homosexuality isn’t actually harmful (just morally reprehensible to some people).

    Putting violent criminals behind bars is often, but not always, the best solution we have. It’s the best we have for Paul Bernardo but it wasn’t the best solution for all of Liberia’s child soldiers.

    If the goal is moral condemnation, excommunication should be sufficient; no bars necessary.

    * We do, however, imprison people for fraud and theft.

  73. geo “You seem to prefer believing whatever it is you think will suit you best. Maybe you should try harder?”

    Well then, you know all about me that you need to and have found your “truth.”

  74. geo says:

    “• Because they are dangerous. It keeps them away from children for a period of time and keeps them within the system for a further period of follow-up of debatable effectiveness once they are released.

    • As a deterrent of debatable effectiveness, for themselves and for others.

    • For justice to be seen to be done (yet more debatable effectiveness). ”

    What make you think they are dangerous? Maybe it’s a good thing to have them rape children? Why should we deter this behaviour unless it is because we think it should be morally condemned?

    You’re just presuming that we can condemn this sort of behaviour, but then attacking my explicit claims that this is the case for being smug.

    “If the goal is moral condemnation, excommunication should be sufficient; no bars necessary.”

    ? The goal is not moral condemnation. If it were, not even excommunication would be necessary. What are you talking about? There’s been no previous discussion as to the costs and benefits of prison and I’m not sure why you’ve chosen to now focus upon this.

  75. geo says:

    “Well then, you know all about me that you need to and have found your “truth.””

    I still don’t know why you think this is an acceptable approach to morality. Maybe you don’t either?

  76. geo – Sometime, when you want to understand, perhaps you could go back and read my posts without adding assumptions…you may get closer.

    But you are right, sometimes I don’t know. Life’s ethical questions often are more subtle and demanding than ‘child rape, right or wrong?’.

  77. There are lots of things that people are accountable for and that we think are bad without making moral judgements.

    For instance, there is nothing immoral about having Type 1 diabetes, yet the person who has it still bears the burden of controlling their blood sugar and will suffer death or loss of limbs and organs if they don’t. The rest of us usually think that someone dying of uncontrolled blood sugar is a bad thing, particularly bad if that outcome could have been avoided. In general, we choose to arrange that people with Type 1 diabetes have access to the means to control their blood sugar, and we are sad and disappointed when they don’t use them. In this sad outcome, some of us would even go so far as to question whether the means were sufficiently accessible and take responsibility for making changes to the way the means are delivered.

    A person with uncontrolled Type 1 diabetes who is obese, has had their legs amputated, is blind and on dialysis and who is rude and abusive to their staff and health care support is probably not going to get as good care or live as fun a life as someone who faces life with better grace. This will happen naturally without anyone sitting in moral judgement. Health care staff who are able to suspend moral judgement and offer professional care despite the difficulties are usually considered to be better people than those who are not.

    We don’t have to get exercised about whether it’s immoral to have a paraphilia, a personality disorder or impulse control problems to believe that sexual assault is a bad thing and that it’s particularly bad when the victim is a child. Whether it’s immoral to have a Paul Bernardo-type personality disorder or not, we still need to decide what we do when someone has one. Right now, what we do includes bars.

    Just as someone with Type 1 diabetes will end up with significant health problems if they do not control their blood sugar even if I don’t make a special effort to perceive Type 1 diabetes as a moral failing, people who can’t arrange not to be violent and disruptive end up in prison even if I don’t make a special effort to perceive Paul Bernardo as being morally culpable. It doesn’t matter. He’s in prison and I can’t think of a better place for him to be.

    For their sakes, I hope that the prison staff are able to treat him professionally and not use their feelings of moral revulsion as an excuse to treat him worse than necessary.

    You were the one who asked why we used bars. I answered.

  78. word of the day:scrupulosity

    Just my luck to not have some more common Christian expression. I’ve got to come down with the convoluted Socratic version.

    So, I really must redirect my attentions to the more productive pursuit of gluing bits of wood into boxes for assemblages with inspirational images, so that I might possibly make some money (or not, in this economy.)

    geo – Good luck with the fibro (if I’m correct in deducing that is a condition you struggle with), I hope they find a more effective treatment soon.

    alison – Good luck with the explanation. :)

  79. geo says:

    @ MM:

    “geo – Sometime, when you want to understand, perhaps you could go back and read my posts without adding assumptions…you may get closer.”

    Funny to follow that up with:

    “geo – Good luck with the fibro (if I’m correct in deducing that is a condition you struggle with), I hope they find a more effective treatment soon.”

    If I was riddled with incessant pain from an unknown disorder I’d be sky-high on a cocktail of drugs rather than endlessly posting comments here. But probably thanks anyway?

    “Life’s ethical questions often are more subtle and demanding than ‘child rape, right or wrong?”

    Life is complicated and confusing but that doesn’t mean we should pretend that we cannot work to find what is most likely to be true. We can for medicine and we can for morality. We should always ensure that we remember just how partial our understanding of life is, but that’s a reason to work harder not to avoid asserting even the most basic of moral truths.

    @ AC:

    “There are lots of things that people are accountable for and that we think are bad without making moral judgements.
    For instance, there is nothing immoral about having Type 1 diabetes, yet the person who has it still bears the burden of controlling their blood sugar and will suffer death or loss of limbs and organs if they don’t.”

    They bear this burden for reasons of efficiency rather than personal accountability. It’s rather more efficient to have the individual patient control their own blood sugar level than to farm this burden out to others. Were diabetes treatable in a manner which required an annual application of some highly skilled technique, then for efficiency reasons we would expect this to be provided by an expert who specialised in the field, rather than have each individual patient having to learn the technique themselves.

    “Just as someone with Type 1 diabetes will end up with significant health problems if they do not control their blood sugar even if I don’t make a special effort to perceive Type 1 diabetes as a moral failing, people who can’t arrange not to be violent and disruptive end up in prison even if I don’t make a special effort to perceive Paul Bernardo as being morally culpable. It doesn’t matter. He’s in prison and I can’t think of a better place for him to be.”

    Right. I’m not arguing that it is immoral for someone to be sexually attracted to children. It is the individual engaging in the act of abuse itself which requires moral condemnation, and that is true even if the act were a result of mental illness.

    “You were the one who asked why we used bars. I answered.”

    In response to your claim that: “You can diagnose a child rapist with a paraphilia, a personality disorder and an impulse control disorder and decide that the best place for them is behind bars” I asked “Why should we put them behind bars unless we have decided that their behaviour deserves moral condemnation?”

    You then explained the dubious history of punishing people for poorly thought out reasons and then answered the question with “Putting violent criminals behind bars is often, but not always, the best solution we have” – presumably ‘best’ being an appeal to pragmatic considerations of some sort.

    Yet to consider whether prison is an optimal pragmatic solution for different types of behaviour we first need to make moral decisions about the sort of behaviour which people should be free to engage in and the sort of behaviour we want to reduce. You said: “We don’t have to get exercised about whether it’s immoral to have a paraphilia, a personality disorder or impulse control problems to believe that sexual assault is a bad thing and that it’s particularly bad when the victim is a child.” But why do you think the sexual assault of children is a bad thing? You don’t have to get exercised about anything to answer the question but doesn’t this sort of judgement require some sort of appeal to moral truths, regardless of how keen you are to avoid doing so? Why should the desires of the paedophile be seen as less important than the desires of the child? Pragmatism requires a clear moral foundation and understanding as to what these pragmatic calculations are attempting to achieve, or else it will serve to legitimise all sorts of repulsive behaviour. I find it strange that supporters of pragmatism seem so happy to keep bringing up the possibility of using moral arguments to condemn homosexuality while conservatives flood American air-waves with pragmatic moral arguments against the official recognition of homosexual relationships.

  80. Tai Chi is supposed to have an essential mechanism of action. At least one or more. If any of these are “outside” of “western medicine,” then it would be considered “alternative.” An example would be if someone asserts that Tai chi works by re-directing “chi,” the life-force in the body.

    Chi is not really a concept in western medicine.

    For tai chi to be validated, by an empirical, scientific, western evaluation, as having a benefit due to its woo conecpt, then the woo concept has to be measured, and seen as having an efect over the other factors – cameraderie, physical relaxation, unconditional positive regard, social involvement, loosening tight muscles, and so on.

    Chi was not measured in this study. And the reductionist, western factors were not controlled, as noted in the OP.

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