When we were forming the National Council against Health Fraud I wondered aloud to the president, Bill Jarvis, what we would do if society solved the chiropractic problem. Bill laughed and said there would never be an end to quackery claims.
How right he was. But why? Many express surprise that at this time of remarkable intellectual and scientific advance, so many people choose to believe in irrational medical claims. The answer I am used to is the one that explains the difference between the attraction of subjective versus the dryness of the objective; between reflex and conditioned responses and rational thought, and between immediate emotionally gratifying, low-level mid-brain reactions and slow-reacting, cool, higher level intellectual thought. These comparisons are all valid but in trying to answer the question, we can miss the constancy of human nature biology, the dimension of time flow, the changing nature of evidence, and as yet unemphasized, the changes and evolution of measurement.…
Before Evidence Based Medicine (EBM) was devised, and the randomized clinical trial (RCT) accepted as the so-called gold standard, our evidential decisions turned on balances or ratios of science/nonsense, rationality/irrationality, reality/delusion, and an estimate of plausibility/implausibility. We can see now that the concept of EBM introduced a new set of standards to our equations balances – proof by RCT and their derivatives, systematic reviews (SRs). The demand for proof by RCT and and SR relegated the previous standards, the unbalanced ratio concept, to the level of anecdote and “uncontrolled observation.” We had to start over again with a new standard.
There are several thought tangents that develop from this problem – one is describing truth or at least validity in a field in which the objects of investigation are in constant change. At the same time, so are the measuring devices. The problem of change affords our critics a more valid basis for criticism, especially via the tu quo que argument (Hey, your guys aren‘t any more valid than we are…) . But recognizing this set of affairs principle may help us understand why sometimes we feel cornered by quacks’ challenges. We have been relying on answers based in logical argument and rationally obtained data, when the actual nature of investigating nature is a slippery one that has pulled a floor of conviction out from under our feet. We have to investigate a changing, evolving set of conditions and diseases, plus the eruption of new ones such as HIV) and changes in classification from increased understanding of mechanisms. While changes in basic science and technology and we develop increased understanding of disease:health interacions, others of us change our measuring devices. Yikes.
On the other side of the ledger there is a constant strain of human nature that demands belief and solidity for one’s mental health. This need is the direct basis for the various world religions used as explanatory reasons for existence and explanation of the unknown.
As a reaction to beliefs in creation myths and in mystical origins for group ethics standards, Relativism and Post-modernism arose in the 1970s as if a counterbalance the older belief system. PoMo introduced more mischief into the medical system than any other new concept, by undermining the scientist’s reliance on a basic fund of knowledge. They also sabotage rationalists’ efforts to counter scientific nonsense and absurd propositions. .
All this led to several veins of thought that might have been introduced here before, but I cannot recall it. First, the thinking processes of quacks and followers. As delusional, utopian thinking acts as a warping lens of reality, our own standards are not stationary, a fact putting us at an unrecognized disadvantage. The problem becomes one that places our demands for proof on slippery ground – to what standard do we expect quacks to adhere?
Beside the morphing of our facts, our rationalist researcher brethren in their wisdom keep refining our measuring devices as well. The RCT was developed after WW II, mainly after 1960. It was preceded by observational studies and non-randomized, non-blinded trials. But the RCT is still in development – I the fine-tuning stages. Thus, results obtained 20 years ago may not be accurate enough by today’s standards. Then in the 1990s came EBM and its standard, the systematic review (SR). Srs are also still in development and are being shown to be inadequate for disproving claims based I subjectivity and claims that are implausible. The measuring device of the RCT is not fine enough or accurate enough to detect fraud, misrepresentation, and a host of methodological errors.
Thus our definitions of our standards are also movable. These problems place us closer to our post-modern opponents than is comfortable – at least on te surface. We also change definitions of truth and reality. Yet, less our adversaries in quackery, relativism, PoMo, and commercial fraud take hope from this dilemma, there is an answer, based in the same criteria mentioned in the beginning. Rationality, honesty, authenticity, plausibility, and validity will still trump their opposites. (Richard De Mille explains authenticity and validity in his SRAM article on how he investigated the fraud that was Carlos Castaneda.) How to tell? How could we know this? First, we can re-read Kim Atwood’s series on plausibility, and follow this strain of discussion as we develop in future posts. Kim helped to clarify for me the dilemma I faced in 1999 in that Net zine discussion with Renner, Walach, Ernst, and others in which I felt as moderator I had to bring plausibility to a discussion of evidence based on RCTs, yet found it hard to justify it in such a forum. Second, What may be needed is a new approach and a new language to express the four or more criteria of rationality, honesty, authenticity, and validity. Third, the project we are developing on quantifying error and misrepresentation. Can the rest of you offer some angles on this? I will be doing the same, working on subsequent posts the next few weeks.