Labels are a cognitive double-edged sword. We need to categorize the world in order to mentally capture it – labels help us organize our mental maps of the overwhelming complexity of things and to communicate with each other. But labels can also be mental prisons, when they substitute for a thorough, nuanced, or individualized assessment – when categorization becomes pigeon-holing.
We use many labels in our writings here, out of necessity, and we try to be consistent and thoughtful in how we define the labels that we use, recognizing that any sufficiently complex category will be necessarily fuzzy around the edges. We have certainly used a great deal of electrons discussing what exactly is science-based medicine, and that the label of so-called alternative medicine is really a false category, used mainly for marketing and lobbying (hence the caveat of “so-called”).
We get accused of using some labels for propaganda purposes, particularly “antivaccinationist” (often shortened to “antivaxer”). Also “denier” or “denialist”, as in germ-theory denier. Even though we often apply labels to ourselves, no one likes having an unflattering label applied to them, and so we have frequent push-back against our use of the above terms.
There are many medical pseudosciences that persist despite a utter lack of either plausibility or evidence for efficacy. Some practices emerged out of their culture of origin, or out of the prevailing ideas of a pre-scientific age, while others were manufactured out of the imagination of perhaps well-meaning but highly misguided individual practitioners. They were just made up – homeopathy, for example, or subluxation theory.
Iridology belongs to this latter category – a system of diagnosis that was invented entirely by Ignatz Peczely, a Hungarian physician who first published his ideas in 1893. The story goes that Peczely as a boy found an owl with a broken leg. At the time he noticed a prominent black stripe in the iris of one eye of the owl. He nursed the bird back to health and then noticed that the black line was gone, replaced by ragged white lines. From this single observation Peczely developed the notion of iridology.
Peczely’s idea was that the iris maps to the rest of the body in some way, and therefore the flecks of color in the iris reflect the state of health of the various body parts. This basic approach to diagnosis or treatment is called the homunculus approach – the idea that one part of the body maps to the rest of the body, including the organ systems. Reflexology, auricular acupuncture, and even straight chiropractic follow this approach.
At SBM our mission is to promote the highest standards of science in medicine, and to explore exactly what that means, both in the specific and the general. We do spend a lot of space criticizing so-called CAM (complementary and alternative medicine) because it represents a semi-organized attempt to reduce or even eliminate the science-based standard of care, and to sow confusion rather than clarity as to how science works and what the findings of medical science are.
CAM proponents tend to use the same bad arguments over and over again. They have no choice (other than deciding not to be CAM proponents) – if a treatment were backed by solid logic and evidence it would not be CAM, it would just be medicine. As SBM’s fourth year comes to a close I thought I would round up the most common bad arguments that CAM proponents put forward to defend their position. Like creationists, pointing out the errors in their facts and logic will not stop them from continuing to use these arguments. But this lack of imagination on their part makes it somewhat easy to counter their arguments, since the same ones will come up again and again.
The argument from antiquity
Our SBM colleagues in Australia have been critical of the incorporation of unscientific methods into academia. In defense of this practice:
Professor Iain Graham from Southern Cross University’s School of Health yesterday defended his university, saying the use of alternative therapies, such as homeopathy, can be traced as far back as ancient Greece.
This is a common claim – that some CAM modalities have been around for centuries, or even thousands of years, and so they must work. I am not sure if professor Graham intended to state that homeopathy can be traced back to ancient Greece, perhaps he just meant that some CAM therapies can, and chose homeopathy as a bad example. For the record, homeopathy was invented by Samuel Hahnemann about 200 years ago.
Michael Specter is a good science journalist. I particularly enjoyed his book, Denialism. In a recent New Yorker article he tackles the difficult question of the placebo effect in modern medicine. While he does a fair job of hitting upon the key points of this question, I think he missed some important aspects of this question and allowed the views of Ted Kaptchuk to overly influence the framing of the article. Specter fell for the typical journalist trap — frame the article around a charismatic “maverick”, complete with compelling anecdotes, bury the meat of legitimate skepticism deep in the article, but then bring it all back to the maverick in the end. Be sure to tell us how this is going to change everything. This is good story telling, but very problematic as science journalism.
Kaptchuk himself is an interesting character. He is heading Harvard’s Program in Placebo Studies and the Therapeutic Encounter. He has produced some good science on the placebo effect, but does not seem to want to draw the appropriate lessons from that research, and passes his bias on to Specter. From the article the quotes from Kaptchuk that most strike me are those about his personal experience with placebo medicine. Specter reports:
“There was no fucking way needles or herbs did anything for that woman’s ovaries,” he told me, still looking mystiﬁed, thirty-ﬁve years later. “It had to be some kind of placebo, but I had never given the idea of a placebo effect much attention. I had great respect for shamans—and I still do. I have always believed there is an important component of medicine that involves suggestion, ritual, and belief—all ideas that make scientists scream. Still, I asked myself, Could I have cured her? How? I mean, what could possibly have been the mechanism?”
Four months ago David Gorski wrote about the College of Physicians and Surgeons of Ontario’s (CPSO) draft policy on “non-allopathic” medicine. He pointed out:
It’s obvious from the wishy-washy approach to the scientific basis of medicine, the waffle words when it comes to whether an “allopathic” physician should support “non-allopathic” therapies, and the apparently inadvertent use of language favored by quacks that there were far too many “alternative” practitioners involved in drafting this policy.
I agree. The proposed policy addresses the issue of so-called complementary and alternative medicine (CAM) and has drawn serious criticism from Canadian physicians (at least those who are paying attention and have the slightest clue about what is going on). The backlash is good to see, but it is not nearly vigorous enough.
There is now an update to this story as the CPSO has published a revised policy proposal. There are some improvements, based on the criticism, but still there are problems with the policy.
Prince Charles is a big supporter of “natural” medicine, which in practice means unscientific and ineffective medicine. He has no particular expertise in this area, and there is absolutely no legitimate reason why he should have any influence over the practice of medicine in the UK. But he is the Prince of Wales, and he has chosen to use that celebrity to promote CAM.
Prince Charles has also recently been criticized for his credulous support for medical nonsense. The Telegraph recently reported that Simon Singh, co-author with Edzard Ernst of Trick or Treatment, and exposer of CAM pseudoscience, spoke about Prince Charles at the recent Hay Festival in India. Singh had some sharp criticism, including:
He only wants scientific evidence if it backs up his view of the natural treatment of health conditions…
We presented evidence that disputes the value of alternative medicine and despite this he hasn’t changed his mind…
Chiropractic is a diverse collection of beliefs and practices occurring under a broad regulatory label. The differences among various chiropractics are so stark that it is difficult to make general statements about chiropractic practice. At one end of the spectrum, however, are so-called “straight” chiropractors who adhere to the original philosophy of D.D. Palmer – that a vital force they call innate intelligence is response for health, and blockages in the flow of this magical force through the nerves are what cause illness. Such chiropractors believe they can influence non-neuromuscular conditions by restoring the flow of innate blocked by mysterious “subluxations” in the spine.
From chiropractors.org we have this definition of “straight” chiropractors:
Because straight chiropractors believe that nearly all diseases are caused by issues with the spine, they don’t believe they need any diagnostic tools. Traditional testing done by medical doctors and hospitals is not even considered by a straight chiropractor as being necessary. Diagnosis is done by finding the subluxations in the spine so that those can be corrected.
This particular version of chiropractic (by some estimates about a third of chiropractors follow this philosophy) is pure pseudoscience. It is, as indicated by the quote above, hostile to science-based medicine. After a century of such belief there isn’t a bit of evidence to support the notion of innate intelligence, chiropractic subluxations, or health benefits from this approach.
Scientific medicine is not easy. By this point we have largely picked the low hanging fruit, and continued improvements are mostly incremental and hard won. In order to get the most out of our limited research dollars, and optimize medical practice with the safest and most effective treatments, we need to use all available scientific evidence in the proper way. That is the essence of SBM.
There are those, however, that misuse or abuse the scientific evidence — whether to promote an ideology, out of innocent ignorance, or for nefarious purposes. In order to be truly science-based a medical intervention should be plausible, or at least not implausible, based upon basic science evidence, and it should actually be safe and effective when tested in people. Therefore, medical practices can fail to be scientific for one of two broad reasons: they can be scientifically implausible, or they can lack proper clinical evidence for safety and efficacy (or even have evidence for lack of efficacy). Some modalities (like homeopathy) fail on both counts.
The more pernicious medical claims are those that seem highly plausible, that can be extrapolated from basic science, but simply lack adequate clinical evidence. Stem cell clinics are an example — they can easily dazzle desperate patients with scientific descriptions of how stem cells work, and even cite published basic-science papers showing the potential of this technology. But what they cannot do is provide clinical evidence that the specific intervention they are offering is safe and effective for the specific disease or condition they are treating.
There is an endless stream of supplement products on the market that are of questionable value. They tend to follow a similar pattern: put an essentially random assortment of vitamins, minerals, perhaps herbs and nutritional elements into a pill and then make whatever pseudo-health claims you want. Usually the claim is implied in the name of the product itself – sleepwell, or brainboost. The popular product Airborne fits this mold. It is essentially a multivitamin with the unfounded claim that it will prevent infection by boosting the immune system.
In the US, regulations (under DSHEA) specifically allow “structure/function” claims without any requirement for evidence to back up the claims. In other words, as long as you don’t mention a disease by name, you can make pretty much whatever claim you want. This was supposed to be good for the consumer, when in fact it is springtime for industry at the expense of the consumer. If your claims are outrageous enough the FTC can still go after you, but they are playing a game of whack-a-mole and losing.
Another pattern that is common is for a supplement product to contain specific components that are claimed to have specific benefits. Often these claims are based upon evidence – just the wrong kind of evidence. Basic science evidence is used inappropriately to support clinical claims. This strategy is more insidious, as it gives the public the sense that the product is science-based when it isn’t.
Reiki (pronounced raykey) is a form of “energy healing,” essentially the Asian version of faith healing or laying on of hands. Practitioners believe they are transferring life energy to the patient, increasing their well-being. The practice is popular among nurses, and in fact is practiced by nurses at my own institution (Yale).
From reiki.org, we get this description:
Reiki is a Japanese technique for stress reduction and relaxation that also promotes healing. It is administered by “laying on hands” and is based on the idea that an unseen “life force energy” flows through us and is what causes us to be alive. If one’s “life force energy” is low, then we are more likely to get sick or feel stress, and if it is high, we are more capable of being happy and healthy.
Reiki is therefore a form of vitalism – the pre-scientific belief that some spiritual energy animates the living, and is what separates living things from non-living things. The notion of vitalism was always an intellectual place-holder, responsible for whatever aspects of biology were not currently understood. But as science progressed, eventually we figured out all of the basic functions of life and there was simply nothing left for the vital force to do. It therefore faded from scientific thinking. We can add to that the fact that no one has been able to provide positive evidence for the existence of a vital force – it remains entirely unknown to science.