Nov 10 2011

When Science Fails – Bully

There seems to be no end to the questionable tactics of CAM promoters. The one thing they do not have on their side is the science. Two decades ago, when they really started clamoring for legitimacy, their frequent cry was that all they wanted was a fair chance to prove that their modalities worked. They claimed that treatments like acupuncture and homeopathy were simply not studied, and once they were properly studied the world would see how effective they were.

Now, two decades and billions of research dollars later (mostly through the NCCAM) the evidence is increasingly clear – these modalities are alternative for a reason, they don’t work. Those clinical trials that are well controlled an rigorously designed demonstrate that acupuncture, homeopathy, reiki, and similar methods do not work any better than placebo. They are physiologically inert.

If proponents were intellectually honest, they would have simply admitted this and moved on. But CAM proponents use scientific evidence (to borrow an excellent metaphor) as a drunkard uses a lamppost, for support rather than illumination.

The more negative evidence comes in, the more desperately they try to distract from this fact. So they misrepresent the evidence, cherry pick the positive data, advocate for unblinded “pragmatic studies”, confuse placebo effects with specific effects of their intervention, and still maintain that “Western” science cannot penetrate their arcane modalities. It’s all smoke and mirrors, meant to deceive.

Meanwhile they have simultaneously pursued a suite of strategies meant to achieve through legal maneuvering, bribes, and bullying what they have been unable to achieve through scientific evidence. For example, the British Chiropractic Association (BCA) sued Simon Singh for libel because he correctly pointed out that they promote treatments that are not based upon science and evidence. Most amusing in this episode was when the BCA put together a list of studies that support their treatments, only to clearly demonstrate that the science does not support chiropractic manipulation for the childhood disorders in question, and that the BCA is either incompetent or dishonest in claiming that there is (in essence they proved Singh’s point for him). Various members of the anti-vaccine movement have sued Paul Offit on several occasions for criticizing their dangerous pseudoscience. And the homeopathy giant Boiron has sued an Italian blogger for pointing out that Oscillococcinum is pure unadulterated nonsense – to point out just a few cases.

In addition to libel suits, proponents have also pursued a number of regulatory avenues, such as pushing for “health care freedom laws,” the true purpose of which is to remove the ability for states to maintain a standard of care (similar to the academic freedom approach of evolution-deniers). Such laws stipulate that the state cannot act against a practitioners license simply because what they are doing is not based upon a standard of science and evidence, as long as they label their practice “alternative.” In my home state of CT a specific law was passed protecting the pseudoscientific treatment of alleged chronic Lyme disease. Proponents of this notion could not convince the medical community with actual science, so they got naive legislators to make an end-run around the science by passing a law. Proponents of dubious medical practices are also tirely in promoting not only friendly legislation but licensure and mandating coverage by insurance companies.

CAM proponents found it difficult to penetrate academia, but they overcame that obstacle – not by providing academically respectable evidence for their claims, but by paying large sums to medical schools to open up centers for integrative medicine. Essentially they have had some success in carving out special spaces within academia where the normal rules of academic legitimacy do not apply, in the name of openness and diversity. If you try to point out this fact then you are labeled protectionist, elitist, closed-minded, and mean. Clearly the problem must be with you, and not the rank pseudoscience that is worming its way into academia.

Now we have run across yet another strategy to bypass science and promote dubious medical practices through strong-arming intimidation. The new approach is to exploit the notion of informed consent in order to argue that physicians who do not present alternative options to their patients are being unethical. In a recent paper published in Pediatrics, the authors write:

As the evidence for a particular therapy (whether conventional or CAM) grows and it becomes more accepted in the medical literature, clinicians’ duty to disclose information about them can be expected to expand accordingly as well.

The specific example they use is acupuncture for chemotherapy induced nausea and vomiting. This is a useful example, actually, because it highlights the problem with EBM and CAM – the evidence for acupuncture for this symptom is weak and inconsistent. The best reviewers can say about the evidence is that more research is warranted. But when the low plausibility for acupuncture is considered, plus the documented publication bias, and the fact that acupuncture has been studied for many different indications, the fact that the evidence is weakly positive for one indication by chance alone is not surprising. A science-based looked at this treatment, in my opinion, leads to the conclusion that it probably does not work, and is certainly not above the threshold where one could argue it is the standard of care and not offering it as an option violates informed consent. Yet that is exactly what the authors are arguing.

There is a not-so-subtle threat implied in the article, strengthened by the fact that one of the co-authors is Michael Cohen, a lawyer who has been aggressively promoting alternative medicine. (Orac has a more thorough discussion of the paper.) I also find it ironic that CAM practitioners are simultaneously pushing for laws that give practitioners freedom from any standard of care, but then try to invoke the standard of care when they believe (falsely) that one of their favored modalities has eked across the line to being part of the standard of care.

We can now add the (mis)informed consent gambit to the long list of dubious and intellectually dishonest methods that CAM proponents use to advance their agenda, despite the lack of scientific evidence for their claims. Unfortunately, much of the public, including legislators and academics, are unaware of these tactics or the true scientific status of many CAM claims. My own experience is that many academic physicians simply do not know what CAM modalities truly claim, and frankly do not believe the skeptics when they point out how unscientific they are. They naively have a hard time believing that the claims can be that egregious.

Which means that our best weapon in the fight to maintain the science-based standard of care in medicine is the simple truth.

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10 responses so far

10 Responses to “When Science Fails – Bully”

  1. daedalus2uon 10 Nov 2011 at 9:45 am

    I submitted an eLetter contrasting the difference between the ethical duty of a Physician (first do no harm) and that of a Lawyer (vigorously advocate for a client but don’t do anything illegal).

    Physican ethics simply don’t allow using or suggesting non-standard of care treatments and that includes placebos like acupuncture.

  2. Jim Shaveron 10 Nov 2011 at 10:28 am

    Thanks, Steve. I can always count on you to get my blood boiling early in the morning.

    The other day, I attended an open house event at my son’s grade-school, where they also had a health fair in the gym. I put on my “Skeptic’s Guide to the Universe” T-shirt (which I often wear at public gatherings such as this) and went into the health fair, half expecting to see at least some form of SCAM (“So-called CAM”, as I like to put it) in there.

    Sure enough, the local chiropractor was represented there by his wife and a nurse, and they were offering some sort of free spinal measurements (which certainly did look impressively technical, with a little hand-held ultrasound device connected to a notebook computer). Among the many services listed on the sign was acupuncture, so I thought I would stop and ask the ladies a few questions.

    The nurse told me that acupuncture works by removing toxins from the body, using the body’s “pressure points”. I said, “Really?! I had no idea. So are the needles hollow, then?” She said they were not hollow and were very tiny, so I asked her how the toxins were removed, and she referred me to the chiropractor’s wife, who “knows a lot more about it.”

    When I talked to the chiropractor’s wife, I started by asking what acupuncture is and how it works. Her answers astonished me. She began listing all the ailments it can cure. Second on the list after pain was infertility, so I asked her how it was possible that poking tiny needles into a woman’s skin nowhere near her reproductive organs could cure her infertility. She said that her husband was an expert, with 400 hours of acupuncture training, the “most you can get” (?!), and that a woman came in and they cured her.

    I was tempted to say, “You’re husband has 400 hours of training in nonsense,” but instead I told her that I was surprised to hear that acupuncture could cure diseases, and that I would have to investigate further. (I kept hoping that she would read my T-shirt, but I don’t think she ever did.)

    Sometimes I get so angry at how this crap has pervaded our society, and I feel mostly powerless to fight it. Oh yeah, I also learned that my son’s first grade teacher has the class say a prayer together before lunch every day. This is a public school.

    Steve, you’re an inspiration. Please keep doing what you do to fight superstition and medical quackery. I’ll keep asking questions. Now I need to go make an appointment to talk to the principal.

  3. HHCon 10 Nov 2011 at 10:59 am

    The “Drunkards” like to pee outside, a la Dr. Buttar. The health care freedom laws simply wash the sidewalks afterwards.

  4. Tom Nielsenon 10 Nov 2011 at 12:45 pm

    Sometimes I get so angry at how this crap has pervaded our society, and I feel mostly powerless to fight it.

    @Jim
    I think a lot of us are in the same boat. I have slowly seen how CAM has creeped into my near social circles, most of them having university degrees even.

    I even know two medical students buying into acupuncture, who no matter how thoroughly I shred their arguments to pieces from every angle (in a civil way of course), persists in the “but if a person feel that it works, well then it works” argument.

    And this is after I have gotten them to acknowledge it is pure placebo by explaining the lack of plausibility and the research. And after I have told them that even a small risk is unacceptable for placebos, and that it takes focus away from legitimate treatments, plus it can be resource exhausting – thus hurting people with limited time/money/energy.

    A lot of people just tend to let their gut conquer all reason, no matter what you tell them.

    At least I have managed to convince a couple of people who just didn’t know a lot about the subject, but thought acupuncture was legitimate.

    Especially one friend I have, a really sweet woman, has turned out to be quite into some far out woo. The problem is that it is so so hard bringing up the subject and keep a friendly tone, because you are implicitly criticizing their beliefs and intellect. It is also hard to debate the subject in a casual non conflicting way, without coming of as a dick.

    This of course doesn’t mean I will stop trying, but it is so f’ed up that the truth is an uphill battle, because correcting misinformation and misconceptions is many times harder than spreading them.

  5. nybgruson 11 Nov 2011 at 3:44 am

    @Tom Nielson:

    It is an uphill battle because it is much easier to go with the CAM answer than actual science.

    To bolster your spirits (and hopefully those of others here) I had a number of my med school classmates who were in the same camp. They genuinely thought that acupuncture “worked” and had a “what’s the harm attitude.” After much discussion and a few emails with articles (many here, and SBM as well along with some current PubMed stuff) I have them duly convinced about everything we have learned via active skepticism around these parts. They were truly amazed at the claims and the paucity of evidence and special pleading.

    So I ask each person I take the time to do that with, whose eyes I have opened, not to be an active skeptic and write constantly about it (since that is a lot of effort and not everyone is up for it) but merely to spread the word whenever they can over their careers. Get people thinking a bit. Stop people from being shruggies. And stand firm when nonsense comes their way. I explained to them that if they can do so for just a handful or two of people and just a couple of those do the same, we can keep things moving the right way. They’ve agreed and I feel like I’ve done my part (for now).

  6. daedalus2uon 11 Nov 2011 at 10:29 am

    My eLetter was publshed and is available to be seen even by those without access.

  7. DevoutCatalyston 11 Nov 2011 at 12:06 pm

    @daedalus2u
    Do you have a link? I can’t find a way to view it without access.

  8. daedalus2uon 11 Nov 2011 at 3:09 pm

    I think you have to look at the abstract first.

  9. daedalus2uon 11 Nov 2011 at 3:11 pm

    here is a direct link

    http://pediatrics.aappublications.org/content/128/Supplement_4/S187.abstract/reply#pediatrics_el_51800

  10. eiskrystalon 14 Nov 2011 at 3:55 am

    I will extend the metaphor and point out that they are not only using the lampost (evidence) for support… if you know what I mean.

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