Answering another criticism of science-based medicine

In the three and a half years that the Science-Based Medicine blog has existed, we contributors have come in for our share of criticism. Sometimes, the criticism is relatively mild; often it’s based on a misunderstanding of what SBM is; but sometimes it’s quite nasty. I can’t speak for the rest of the SBM crew on this, but I’ve gotten used to it. It comes with the territory, and there’s little to do about it other than to skim each criticism as it comes in to see if the author makes any valid points and, if he doesn’t, to ignore it and move on. Indeed, there’s enough criticism being flung our way that I rarely respond directly anymore. Exceptions tend to be egregious examples, incidents that spark real problems, such as when Age of Autism blogger and anti-vaccine activist Jake Crosby tried to paint me as being hopelessly in the thrall of big pharma, which resulted in the anti-vaccine horde who read that blog to try to get me fired by sending complaints to the Board of Governors at my university and the dean of my medical school. Other examples tend to be what I call “teachable moments,” in which the mistakes made in the criticism provide fodder for making a point about SBM versus alternative medicine, “complementary and alternative medicine” (CAM), or “integrative medicine” (IM)—or whatever the nom du jour is.

File this next one under the “teachable moment” variety of criticism directed at SBM.

A pain researcher takes Steve and me to task

In order to stoke my massive ego (if you don’t believe I have a massive ego, just ask my critics), I have a Google Alerts set to my name. One thing I learn from these alerts is that there are a lot of people out there named David Gorski, few of them doing medicine and not all of them particularly reputable. The other thing I learn is that I’m actually mentioned on the web and in the blogosphere more times than I ever would have imagined possible a few years ago. More importantly, I’m quickly aware of criticisms directed my way. So it was that I found out about an article by someone named Stewart B. Leavitt, MA, PhD entitled A Burgeoning Klatch of Science Skeptics, which managed to attack both Steve Novella and myself in a manner that’s so off-base that it presents said “teachable moment,” much as an earlier criticism by Steve Simon provided such a moment.

You know right off the bat that Dr. Leavitt is going to go far off base when his opening paragraph contains the passage:

As it turns out, skepticism regarding modern science, including the field of pain medicine, is somewhat of an international movement. Its mantra might be “Stop the B.S.” (with the irreverent logo at right); yet, there is an apparent danger of skepticism becoming close-minded cynicism falling into the trap of contempt prior to investigation that might preclude truly objective analyses of research.

The community of skeptics, worldwide, serves an important function in modern society, as they always have. It was probably skeptics who asked, “What makes you think the Earth is flat — where’s your proof?” When it comes to healthcare, skeptics at their best evaluate medical treatments and products in a scientific light, promoting the highest standards and traditions of scientific inquiry; however, at their worst, skeptics may merely be naysayers, stirring up the pot of already-established evidence to draw attention to themselves.

This is the classic confusing of skepticism with nihilism or cynicism. In my experience, sometimes skepticism and cynicism are conflated intentionally by opponents of SBM in order to dismiss skepticism as nothing more than a cynical “Dr. No” approach in which claims are reflexively rejected without consideration, but sometimes (and perhaps more frequently) the two are conflated through ignorance because the difference between the two is not understood. I rather suspect that Dr. Leavitt does not understand the difference. (At least, I will give him the benefit of the doubt.) And this criticism can be true to a point: As skeptics we have to be very careful to avoid falling into the trap of cynicism, of rejecting claims without giving them a fair hearing. Indeed, most of us have said as much ourselves on this very blog on multiple occasions, particularly how we ourselves have to try to avoid falling into the trap of motivated reasoning, which is wielded to great effect by proponents of pseudoscience to protect themselves from having to change their minds about cherished views. On the other hand, how many times do clinical trials of pseudoscience like, for example, homeopathy have to fail and how often do we have to point out that the principles by which homeopaths claim homeopathy works violate well-established laws of physics and chemistry before we’re allowed the shorthand of provisionally rejecting homeopathy until its proponents produce data compelling enough to make us question the laws of physics as currently understood?

I won’t take on Leavitt’s criticism of Steve Novella (much). After all, Steve is more than capable of taking care of himself, having been in the skeptic biz at a higher level several years longer than I have. I do note, however, that, although Leavitt links to both Steve’s blog and SBM, he does not directly link to the posts that he cites, making it difficult to see what is being said in context. For example, Leavitt cites Novella as saying:

I have become thoroughly convinced of the axiom that there is no claim so absurd that it cannot attract flocks of true believers. The default mode of human psychology is to think with our emotions, then deftly rationalize our decisions. As a result there do not appear to be any practical limits to human gullibility.

An excellent quote, succinctly summing up the situation. It comes from a post in which Steve deconstructed an example of pure health supplement quackery. In the context of Steve’s post, it makes perfect sense. Yet Leavitt dismisses this as an “emotive” appeal. Similarly, he is very unhappy when I say things that he views as similarly emotive, in particular, when I refer to the “integration” of alternative medicine modalities into medicine as “quackademic medicine” and refer to “integrative medicine” as “integrating quackery with medicine.” I’ll be the first to admit that I came up with these sorts of pithy phrases (aside from “quackademic medicine,” whose origin I cannot claim, as much as I would like to) to make a point in a memorable way that can be easily repeated. This is how one communicates complex topics in a sound bite world, and it worked at TAM in that my point about “integrating quackery with medicine” was Tweeted and re-Tweeted rather extensively.

Of course, it is rather amusing to note that Leavitt dismisses our appeals as “emotive,” while he himself denigrates skeptics using language at least as emotive as ours, describing us, in essence, as cynics who “posture” and preach to the choir in the proverbial echo chamber, such as meetings like TAM, which Leavitt describes as:

The most recent TAM brought together skeptics from around the world and a long list of guest speakers and panelists. Workshops included: Defending Evolution, Skeptical Activism , Advancing Skepticism Online, Investigating Monster Mysteries, Raising Skeptics, and others. And, among the sessions discrediting UFOs and paranormal phenomena were the usual attacks against “alternative therapies” in healthcare and pain management.

Note the dismissive tone about sessions including the “usual attacks” against “alternative therapies.”

More telling is Leavitt’s attempt to contrast the type of skepticism that he claims he promotes, which he characterizes as “healthy skepticism” and “educated skepticism,” with our skepticism. He begins with a nonsequitur:

Along with that, however, we have acknowledged that it is far easier to criticize science — asking tough questions, pointing out flaws or weaknesses — than it is to do good science. Therefore, we were somewhat dismayed by the writings and posturing of the self-proclaimed community of professional skeptics.

So what if it’s easier to criticize science and to point out flaws or weaknesses than it is to do good science? Even if true, this observation on Leavitt’s part serves no other purpose besides denigrating critics of CAM. As someone who does what I like to think is good science myself and has been funded by the NIH, the Department of Defense, and the Conquer Cancer Foundation of ASCO, I find Leavitt’s comment profoundly insulting. His argument boils down to, in essence, a claim that if you don’t do pain research science you aren’t qualified to criticize bad CAM research about pain treatments. From my perspective, though, good science is good science, and bad science is bad science. It doesn’t matter who is doing the criticism; what matters is whether the criticisms are valid. In fact, Leavitt’s use of language is as clever as that of the CAM proponents we routinely discuss. His skepticism is “healthy” and “educated.” Left unspoken is what our skepticism must be—presumably by contrast “unhealthy” and “uneducated”—while Leavitt also characterizes us as “posturing.”

Logical fallacies and false dichotomies on parade

After the warmup, Leavitt gets to the meat of his objections, or so it would appear:

For example, their diatribes against CAM and integrative therapies — which actually can be vital modalities for effective pain management — seem guided more by emotional arguments than a systematic study of all available evidence. Hence, when Novella writes (as noted above), “The default mode of human psychology is to think with our emotions, then deftly rationalize our decisions. As a result there do not appear to be any practical limits to human gullibility,” we wonder if he also is describing how a credulous community of skeptics approach their subjects of scorn.

And, when Gorski asserts that “integrative medicine is all too often in reality nothing more than ‘integrating’ pseudoscience with science, quackery with medicine,” we might assume he has solid evidence to justify such claims; but, if so, he is keeping it secret. And, his far-reaching denigration of NCCAM, the Bravewell Collaborative, and unnamed medical schools adds emotive impact to arguments that might have no basis in fact.

Leavitt amuses me in this passage. His first criticism of Steve is a deftly executed tu quoque argument, in which he seems to concede that the default mode of human psychology is to think with our emotions (which it is, by the way) but turns it around to accuse skeptics of the same thing. Here’s the difference, though. Skeptics know that the default mode of human thought is to think with our emotions, to leap to conclusions first and then to try to find evidence to justify our opinions. Skepticism, science, and critical thinking are all methods designed to try to minimize that very human tendency and to minimize the effects of the cognitive quirks we all share that mislead us, including confusing confirmation bias, confusing correlation with causation, regression to the mean, and placebo responses.

I’m further amused that Leavitt would think that I don’t provide solid evidence to justify my claims. Once again, he doesn’t directly link to the post from which that quote comes, which is entitled The ultimate in “integrative medicine,” continued, which described a cooperative agreement between Georgetown University School of Medicine and the Bastyr University, the latter of which is a school of naturopathy. Clearly, Leavitt doesn’t support the notion that much of naturopathy is quackery and pseudoscience. Even if that’s the case and he disagrees, Leavitt reveals pure laziness in his statement, given that I’ve written copiously, logorrheically even, about this issue, providing numerous examples. For example, here are a few:

  1. The ultimate in “integrative medicine”: Integrating the unscientific into the medical school curriculum
  2. The ultimate in “integrative medicine,” continued
  3. A University of Michigan Medical School alumnus confronts anthroposophic medicine at his alma mater
  4. An open letter to NIH Director Francis Collins regarding his appearance at the Society for Integrative Oncology
  5. “Integrative” oncology: Trojan horse, quackademic medicine, or both?
  6. The National Center for Complementary and Alternative Medicine (NCCAM): Your tax dollars hard at work
  7. Cancer Treatment Centers of America and “naturopathic oncology”
  8. NCCAM Director Dr. Josephine Briggs and the American Association of Naturopathic Physicians
  9. Surprise, surprise! Dr. Andrew Weil doesn’t like evidence-based medicine

As I particularly glaring example selected from the posts above, I submit that the “integration” of anthroposophic medicine with real medicine at my alma mater is the integration of quackery and pseudoscience with medicine.

I’ve also provided multiple lines of evidence on my other blog, and my fellow SBM bloggers have written about this issue, in particular Kimball Atwood. Gratifyingly, we’re even starting to have some success, as the Cochrane Reviews editors have been showing signs of starting to “get” SBM.

Then, after stating that neither Steve nor I have taken the time to study the issues of “integrative medicine” in depth, Leavitt concedes:

Admittedly, the comments above from Gorski and Novella are mere snippets of their voluminous writings, described out of context. Readers can themselves visit the blogs of these skeptics (linked above) to decide the merits of their arguments. For example, we find using words like “pseudoscience” and “quackery,” as they do, to be rather slanderous and empty invectives.

In other words, Leavitt admits to quoting us out of context and then just links to our blogs in general, all the while not providing a single concrete example of our committing the offenses of which he accuses us. These tactics are disingenuous at best and intellectually dishonest at worst, particularly given that Leavitt never bothered to link directly to the posts from which he extracted our comments out of context. Basically, this gambit allows Leavitt to give the appearance of being fair while misrepresenting our arguments and trying to paint us as emotion-driven, biased, and “uneducated” about CAM. Think of it this way. It’s asking a lot—and I do mean a lot—for anyone to visit two blogs that have been in existence for several years, each with thousands of posts, and to try to evaluate the core of the voluminous arguments there. What will happen is that without guidance regarding where to start even the small minority who click on links in a blog post will be quickly overwhelmed by the volume of verbiage and tend simply to accept Leavitt’s characterization without too much investigation.

Leavitt concludes with a false dichotomy:

The lesson in all this is that our understanding of “healthy skepticism,” as advocated in these Pain-Topics UPDATES, may have an objective of “stopping the B.S.,” but it is not necessarily bent on “spoiling anyone’s fun.” And, it is not a close-minded approach that encourages contempt prior to adequate investigation.

Skepticism in pain research should drive a search for truth that recognizes and acknowledges the boundaries of uncertainty. Unfortunately, a great deal of research in the pain field seems driven by political agendas and hidden self-interests, so educated skeptics have much work ahead. We hope our readers are up to the task.

There are two problems here. (Actually, there are more than that, but I’ll concentrate on two.) First, as I said, it’s a false dichotomy. Either you accept Leavitt’s dismissive definition of skepticism, or you’re necessarily “spoiling someone’s fun.” And make no mistake, Leavitt is a pretty credulous fellow. For instance, he has made a holiday “wish list” for “holistic care” that includes a number of pseudoscientific alternative medicine modalities—is that an oxymoron?—including acupuncture, ayurveda, energy medicine (healing touch and reiki), and traditional Chinese medicine, among others. About homeopathy, Leavitt says, “Homeopathy is a therapeutic modality practiced worldwide, it is very popular among some patients, and it has withstood the test of time,” while expressing disappointment in a study of homeopathy for rheumatoid arthritis showed no therapeutic effect and trying to attribute the negative result of the study to its being underpowered. In yet another example, Leavitt critiques Edzard Ernst’s recent review of acupuncture systematic reviews, and while much of what he writes in this particular post is not unreasonable, he can’t help but drop bombs of credulity on the science, saying, for example, that “comparing acupuncture to a molecular entity, such as a drug for pain, may reflect a Western bias regarding how medical treatments are expected to work” and citing an acupuncture proponent who concludes that “it is probably no coincidence that many positive trials of [acupuncture and related techniques] have come from China where the techniques have been practiced for centuries; whereas, studies conducted in other countries often use divergent forms of acupuncture that also may be hindered by poor or improper technique, such as using only a limited number of sites or incorrect acupoints.”

Leavitt then concludes about acupuncture:

Considering the multitude of patients worldwide who have benefitted from acupuncture in one way or another, it still appears premature to broadly dismiss it as being of little or no value for pain relief.

This is yet another appeal to popularity devoid of science.

Finally, I can’t help but cite one last example in which Leavitt discusses “biofield therapies” (reiki, healing touch, etc.):

Although many traditionally-trained practitioners may remain skeptical, significant numbers of patients apparently seek biofield therapies, often without telling their healthcare providers, and the techniques have been used over millennia in various cultures to allegedly heal physical and mental disorders. In general, complementary and alternative therapies are used by 38% of adults and 12% of children in America, and it is a $34 billion per year business; so, these approaches cannot be easily ignored. The customary caveat — more research is necessary to arrive at definitive conclusions — would seem very appropriate regarding biofield-based therapies for pain. However, as the 16th Century Swiss physician Philipus Aureolus Paracelsus advised, “The art of healing comes from nature, not from the physician. Therefore the physician must start from nature, with an open mind.”

I submit that this more than approaches being so open-minded that one’s brains fall out. It embraces such unskeptical open-mindedness and gives it a big, sloppy kiss on the lips. Basically, what we have here is an appeal to popularity plus an argument from ignorance; i.e., that something is likely to be true simply because it hasn’t been proved false or, equivalently, that something is likely to be false because it hasn’t been proved true. Of course, for modalities like energy healing and homeopathy, it’s a fallacy to say that we don’t know. Basic science, such as physics, can tell us with a high degree of probability that homeopathy can’t work, for instance.

Dr. Leavitt’s straw man caricature of skepticism versus positive skepticism

Near the end of his post, Leavitt defines skepticism as “encouraging contempt prior to adequate investigation.” At the risk of sounding “contemptuous,” I am going to say that this is a fetid load of dingo’s kidneys. It’s a favorite straw man characterization of skepticism by the credulous, be they believers in the paranormal, alternative medicine aficionados, evolution denialists, or other promoters of pseudoscience. Personally, in response to such arguments, I like to cite the writings of Michael Shermer regarding positive skepticism:

This brings me to the larger issue of two forms of skepticism, negative and positive. Stephen Jay Gould began his foreword to my 1997 book, Why People Believe Weird Things, by noting: “Skepticism or debunking often receives the bad rap reserved for activities — like garbage disposal — that absolutely must be done for a safe and sane life, but seem either unglamorous or unworthy of overt celebration.”…

Positive skepticism, however, involves much more than the negative disposal of false claims. In fact, the word “skeptic” comes from the Greek skeptikos, for “thoughtful.” According to the Oxford English Dictionary, “skeptical” has also been used to mean “inquiring,” “reflective,” and, with variations in the ancient Greek, “watchman” or “mark to aim at.” What a positive meaning for what we do! We are thoughtful, inquiring, and reflective, and we are the watchmen who guard against bad ideas in order to discover good ideas, consumer advocates of critical thinking who, through the guidelines of science, establish a mark at which to aim. “Proper debunking is done in the interest of an alternate model of explanation, not as a nihilistic exercise,” Gould concludes. “The alternate model is rationality itself, tied to moral decency —the most powerful joint instrument for good that our planet has ever known.”

In other words, not only is “negative skepticism” not cynicism, but it’s actually a good thing. Indeed, skepticism is far more than just the debunking of claims. It’s the application of the best of human reason, including science, logic, and critical thinking to claims. When properly done, skepticism represents the highest intellectual aspirations of humankind. As Shermer points out, skepticism keeps the borders of science from moving too far into the realm of pseudoscience and non-science, and for every Copernicus, Newton, and Einstein, there are hundreds, if not thousands, of cranks and quacks whose ideas never pass scientific muster because they are nonsense. It might be some day that a CAM modality such as homeopathy or energy healing will pass scientific muster. Unlikely, but possible, and if and when that day comes I will examine the evidence and, if appropriate, change my mind to embrace what I formerly considered pseudoscience. That’s what skepticism really is. Moreover, science-based medicine is not an attempt to turn medicine into a pure science; rather it is the philosophy that science should inform and guide medicine.

To conclude, I realize that I perhaps cite this too often and that some might be offended by its language, which some might consider NSFW, but Tim Minchin put it best in his beat poem Storm:

Science adjusts its beliefs based on what’s observed
Faith is the denial of observation so that Belief can be preserved.
If you show me that, say, homeopathy works,
Then I will change my mind
I’ll spin on a…dime
I’ll be embarrassed as hell,
But I will run through the streets yelling
It’s a miracle! Take physics and bin it!
Water has memory!
And while its memory of a long lost drop of onion juice is Infinite
It somehow forgets all the poo it’s had in it!

You show me that it works and how it works
And when I’ve recovered from the shock
I will take a compass and carve “Fancy that!” on the side of my cock.

And I will, too. Well, except perhaps for the part about the compass and carving. We wouldn’t want to go too far, now, would we? On the other hand, one wonders how rapidly Dr. Leavitt will abandon beliefs that he possesses that are not supported by science. Apparently not very quickly. After all, he remains “open-minded” to energy healing, acupuncture, and other unscientific forms of medicine and shows no sign of changing.

Posted in: Basic Science, Clinical Trials, Science and Medicine

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