Dec 24 2008

Defending Science-Based Medicine

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Comments: 8

The following was cross-posted today on Science-Based Medicine.

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Science-based medicine is more than a website. It is a philosophy of medicine that is actively vying with other philosophies for dominance in the world of medicine. We believe that medicine should be based upon the best science available, according to a single universal standard of rigorous methodology and valid logic and reason. Others desire a double-standard, so that they can be free to practice or market whatever they wish without having to meet strict scientific standards. Still others have a non-scientific ideological world-view and want public policy to accord to, or at least admit, their personal beliefs.

I therefore expect that we will be attacked by proponents of unscientific medicine in all its forms.  Yesterday, however, we were attacked on the Evolution News & Views website of the Discovery Institute by creationist neurosurgeon, Michael Egnor. This may seem incongruous at first, but honestly I suspected that just such an attack was inevitable.

Many science bloggers, David Gorski and me prominent among them, have taken on both the DI and Dr. Egnor specifically over many anti-scientific arguments he has put forward over the last couple of years. We have sparred mostly about evolution in medicine, neuroscience and consciousness, and the materialist underpinnings of modern science. Dr Egnor’s day job, however, is that of a (from what I can tell) respected neurosurgeon, so I always wondered what he thought of his sparring partners’ writings about science-based medicine.

His entry yesterday ends any speculation – he wrote an incoherent, logical fallacy-ridden screed that would make any snake-oil peddler proud. This reinforces a point I have made in other contexts – all anti-scientific philosophies have science as a common enemy, and will tend to band together in an “unholy alliance” against those advocating for scientific rigor or defending science from ideological attack. That is why a website that is ostensibly about the “misreporting of the evolution issue” would post a blog attacking science-based medicine as an “arrogant medical priesthood.”

The Straw Man, False Dichotomy, Non Sequitur

The core of Dr. Egnor’s claim is a trifecta of logical fallacies. He writes:

I am not a supporter of “alternative medicine,” and I objected when an effort was made some years ago to expand alternative medicine here at Stony Brook. Alternative medicine, like traditional medicine, must be subjected to strict standards of evidence for safety and efficacy. Most types of alternative medicine fail to meet those standards, and therefore should not be endorsed by the medical profession.

Yet there is an irony in the efforts of “defenders of science” to protect the public from treatments and theories that are outside of the mainstream of medical practice. The greatest iatrogenic danger to patients isn’t chiropractors or homeopaths or vaccine “deniers.” It’s the doctors, nurses, and other medical personnel working in the traditional medical paradigm.

Dr. Egnor has clearly not read enough of our writings, or has not made an effort to fairly understand them, to accurately summarize them. He has earned a reputation as a sloppy thinker and poor scholar for this behavior. Note that he must agree with what we actually do – advocate for “strict standards of evidence for safety and efficacy.” But he wants to find some way to criticize his ideological foes, so the logical fallacies begin. First he constructs a straw man – that our goal is to protect the public from “treatments and theories that are outside of the mainstream of medical practice.” He develops this theme further when he writes:

I believe that much of the motivation for the “pro-science” priesthood isn’t patient safety or a genuine respect for scientific method but ideological hegemony. What bothers materialist ideologues like Novella and Orac is that there are people who challenge their materialist scientific worldview.

Any honest reading of Science-Based Medicine, NeuroLogica, or Respectful Insolence gives lie to this claim, which is no different than the accusations we have heard from homeopaths, energy healers, and charlatans of all stripes. We have clearly written that our purpose is to promote rigorous scientific methodology in medicine. We talk about method, and the targets of our criticism misinterpret this (deliberately or otherwise) as closed-minded “ideological hegemony.” But all we are really saying is that a specific claim does not meet the standards of science and evidence, and that we feel a single science-based standard of care should apply.

Dr. Egnor’s straw man is well known to us because we have heard it from proponents of unscientific medicine for years.  We might argue, for example, that a particular acupuncture study is unblinded and therefore cannot exclude the placebo effect as solely responsible for the outcome. We may also challenge that proponents of acupuncture have yet to propose of scientifically plausible mechanism for their claims. Defenders of acupuncture often counter with the non sequitur that we are biased against acupuncture because it is outside the mainstream and challenges our “materialism.” This does not address our criticisms, however. Such rejoinders are meant as a diversion – to draw attention away from the fact that a particular claim lacks evidence or plausibility.

Proponents of unscientific medicine also rely upon a false dichotomy – that between “mainstream” and “alternative” medicine. The purpose of the double standard is to deflect criticism while simultaneously carving out a double standard for claims that don’t meet the usual standard. We have also been very clear that our goal is to return to a single standard of care in medicine based upon good science.

What’s interesting is that Dr. Egnor can commit the same non sequitur right on the heels of admitting that what we actually do is legitimate. The cognitive dissonance must be deafening.

Tu Quoque

To defend his self-contradictory position Dr. Egnor must create a fiction that he can then criticize – that we aim our criticism outside of mainstream medicine but not within it.

The harm done by traditional practitioners of medicine is one of the leading causes of death in the United States. Where is the introspection by “skeptics” and “science defenders” like Drs. Novella and Orac about the enormous harm done to patients by themselves — traditional medical practitioners? What hypocrites.

This again is based upon a false dichotomy that we are trying to dispel, not promote. We apply the scientific standards we advocate to all of medicine, not just those “outside the mainstream.” It is a point we hammer home over and over, to the point where one must be willfully ignorant to miss it. “Where is the introspection” – one does not have to look far to find it, and so clearly Dr. Egnor did not do his homework (again, true to his reputation).

Just last week I wrote about the abuse of the term “syndrome” in medicine. I did not discriminate according to any false dichotomy about what is inside our outside accepted medicine. I discussed, for example, heavy leg syndrome and chronic fatigue syndrome, both diagnoses accepted within “mainstream” medicine. I have discussed the use of off-label medications, how to interpret the clinical literature, conflict of interest in the medical literature, and the debate about anti-depressant efficacy. David Gorski has written about transparency in clinical trials, barriers to practicing science-based surgery, and when the popularity of new surgical procedures outpaces the evidence. Mark Crislip has sharply criticized our own profession for the acceptance of pharmaceutical company lunches and other perks.

The claim by Dr. Egnor that we do not address issues of science or quality control within our own profession is not only a false dichotomy and a non sequitur, it is patently false.

But of course we do spend the majority of our attention dealing with the most anti-scientific challenges to modern medicine. It only stands to reason that proponents of science-based medicine would spend the majority of their energy attacking the most outrageous unscientific medicine that has managed to infiltrate health care.

Our focus also stems from the fact that this is a niche that we perceive is empty. We are pointing out that the emperor has no clothes because no one else is. The institutions of academia and medicine have been cowed by false notions of political correctness. The AMA was cowed by a successful restraint of trade lawsuit by chiropractors. The mainstream media are worse than useless – they are abetting the spread of pseudoscience. Promoting universal standards of science in medicine and directing our efforts at the worst abusers is our chosen mission. It is a mindless non sequitur (one that we are also familiar with from the proponents of unscientific medicine) to argue that we should be doing something else.

Risk vs Benefit

Which brings me to Dr. Egnor’s other claim – that “mainstream” medicine causes more harm than so-called “alternative” medicine. Dr. Egnor would have done well to first read Harriet’s excellent commentary on this claim. She points out the fallacy of focusing only on harm and not on benefit. Medicine (as any respectable clinician should know) is about risk vs benefit. Focusing on just risk gives a very distorted view of reality.

Of course medical mistakes harm more people than so-called alternative medicine – because mainstream medicine is orders of magnitude larger than alternative practice, and often deals with much more acutely ill patients.

Dr. Egnor focuses on hand washing and medical errors. Why, he wonders, are we not taking on these issues. As stated above, we do in that we advocate for science-based practices across the board. But also, reducing medical mistakes, while very important, is simply not our chosen focus. There are already institutions and systems in place that are working diligently on these problems. In fact, most physicians in academia will serve in some capacity in such efforts as part of their administrative duties. I sit on a credentialing committee that deals with these issues. Mark Crislip tells me he has spent most of his career directly involved in exactly these quality control issues.

So Dr. Egnor’s core claim is just another non sequitur and false premise. He might as well say we are hypocrites for not taking on insurance fraud. Don’t we care about tax payer money being lost due to physicians committing Medicare fraud? What about our colleagues who sexually abuse their patients? Of course we care – it’s simply not the mission of science-based medicine.

I also think that Dr. Egnor misses the boat on these quality control issues. He casually blames arrogance (because it is an easy accusation to throw around). I will admit that there may be a kernel of truth to the notion that personal physician arrogance contributes to poor compliance and medical mistakes. I have never argued that as a profession we are beyond reproach. In fact I often go out of my way to point out that there is much to criticize in mainstream medicine and there are individual physicians who lack compassion, ethics, competence, or all three. (None of which, of course, justifies any particular unscientific claim.)

But the solution to quality control issues is not to rail against arrogance, it is to focus on systems. Those who are actually engaged directly in quality control issues in medicine have learned that you cannot just preach to health care providers about hand washing and diligence. You do need to do this – but the best results occur when systems are put into place that make compliance easy and automatic. Simply placing hand washing gel dispensers outside every patient room did more to raise hand washing compliance than nagging ever could.

These issues are being effectively addressed within medicine.  One of the barriers to efforts to deal with these concerns have been unscientific thinking among our own colleagues. This is not an insurmountable barrier – but we do encounter poor logic and faulty reasoning everywhere. In fact I have argued that making a study of the worst examples of pseudoscience helps me recognize more subtle manifestations of sloppy thinking. Studying pseudoscience makes one a better scientist.

Be Nice

Dr. Egnor’s blog entry also includes this gem:

We are beset by an arrogant medical and scientific priestcraft, eager to call ordinary people “idiots” or “anti-science” or “deniers” because they hold viewpoints with which these particular scientists and physicians disagree.

This is similar to the “Attack on Mommies” gambit that RFK Jr. used to defend his anti-vaccine claims. Again, Dr. Egnor is simply not paying attention, or he doesn’t care. I have written specifically about how to talk to patients who have unscientific ideas. This is an issue about which we are very thoughtful, as it cuts to the heart of what we do.

We in fact have made a specific point not to attack patients or “ordinary people” for holding unscientific views. We have even likened this to “blaming the victim” – we see a scientifically illiterate public as a victim of poor education, a credulous media, and anti-scientific propaganda. We do, however, sharply criticize those who publicly defend or promote pseudoscience or attack science or scientific medicine. We try, in fact, to focus our criticism on their claims and methods and avoid ad hominem attacks.

If you enter the public debate on a topic by writing about it, speaking about it, and actively promoting a point of view – then you open yourself and your views up to criticism. You cannot then whine about being criticized by those who disagree with your point of view. That’s the whole point of public discourse.

Public criticism is also part of the culture of science. Science’s chief strength as a self-corrective system depends largely on open criticism. Scientific discourse, while it can be polite and professional, is also a take-no-prisoners meat grinder. Anyone who has ever attended a scientific conference has likely seen this first hand. Bad ideas are excoriated, as they should be.

Conclusion

This latest entry by Dr. Egnor, true to his form, is an incoherent hodge podge of logical fallacies and contradiction. It is also based on a gross and unfair misrepresentation of the proponents of science-based medicine, as can clearly be demonstrated by what we have actually written on this site over the past year.

It is further evidence that those who seek to undermine the integrity of science in order to promote their personal ideology will find common cause, despite even vast internal ideological differences. That is why Dr. Egnor can agree with our actual position with regard to unscientific medicine, but be so motivated to find something to criticize that he ends up making the same dubious arguments as the proponents of unscientific medicine he claims to oppose. This is why an attack on the defenders of science-based medicine can be found on a creationist website.

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8 responses so far

8 Responses to “Defending Science-Based Medicine”

  1. Michael Meadonon 24 Dec 2008 at 11:00 am

    Excellent post Steve.

    It’s now more obvious than ever that Egnor is nothing less than an anti-reason and anti-science ideologue. That he’s a neurosurgeon to boot never ceases to amaze me. Oh the power of compartmentalization.

  2. thurgoodon 24 Dec 2008 at 2:32 pm

    If anecdotes count for anything, tally one against pseudo scientific cranks and their credentialed defenders. My father was a lifelong practitioner of CAM and became more obstinate after my uncle – a doctor at a prestigious hospital – died of a galloping cancer in months flat. It’s several years since my Dad passed away, so I am willing to forget that acupuncturist who riddled my father’s skin with 100s of pinpricks from crudely sterilised needles dipped in alcohol, provoking sepsis and toxic shock. And chiropractors do kill – softly. One of them delivered the coup de grace to my long suffering mother-in-law who lived for years with rheumatoid arthritis. And if you want t osee vaccination denialists visit the state of Uttar Pradesh in India where mad mullahs have convinced large masses of Muslims that the polio vaccine will render their children impotent, or else we could visit South Africa where circumcision is peddled as a preventive measure against HIV infection. Idiots, cranks, crackpots, misanthropes…I can’t be harsh enough

  3. tooth fairyon 24 Dec 2008 at 7:16 pm

    i really honestly am worried someone like Dr. Egnor could be someone i would have to trust with surgery. He totally misrepresents the data i couldn’t believe it when he went for the SBM has killed more-like dude just stop and think why that is for one second! then think, what the benefit has been, he just needed to read SBM the other day and his intelligence would have doubled i fear. I’m quite glad the the DI has chosen someone who doesn’t do their homework before writing a post to be praised on their site-it’s a great testament to them!!! Good Post Steve

  4. Gated Clockon 26 Dec 2008 at 11:24 am

    Watch out, Dr. N.
    Egnor thinks that you weigh the same as a duck….

  5. eiskrystalon 26 Dec 2008 at 12:25 pm

    When he admits his own mistakes as you do on air and on record, then he may be worth listening to. If only for that apology.

    I fear however that we will be waiting a long time.

  6. Galloping Gauchoon 26 Dec 2008 at 5:16 pm

    Nicely done. If only Dr. Egnor could think and write as coherently. It makes me wonder what deciphering his patient chart notes must be like.

    Thanks for mentioning the quality assurance activities that many (including alt med advocates) seem to be unaware that physicians are heavily involved in as part of our everyday work. I average a good ten hours a week in mandated and non-required quality assurance (QA) activities (including those aimed at minimizing mistakes in medical care). I don’t see any reason why I can’t scrutinize non-evidence based therapies in my free time.

  7. Mjhavokon 27 Dec 2008 at 3:32 am

    It is amazing that someone can be so educated that they become a neurosurgeon but still write such an illogical hodgepodge of a essay.

    Reminds me of Islamic extremists who can be so educated that they become doctors but still crash planes into buildings or cars into airplanes.

    Irrational and illogical believes to hurt and sometimes kill.

  8. gargoyleon 13 Jan 2009 at 2:14 pm

    thurgood,

    I agree with everything you said and can at least understand a smidgen of your frustration (my friend’s mother died from breast cancer after the “crystal therapy” failed, and my mother’s into reiki).

    But in regards to circumcision as a preventive measure against HIV infection, there is truth to that. The foreskin is rather fragile, and sex can create small tears through which the HIV virus can pass. Circumcision (removal of the foreskin) can obviously alleviate this particular danger. Obviously this doesn’t apply to the mutilation known euphemistically as “female circumcision”.

    Here’s a link to the CDC’s fact sheet on circumcision:
    http://www.cdc.gov/hiv/resources/factsheets/circumcision.htm

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