Jul 01 2011

More CAM Debate in the Atlantic

I have stayed only peripherally involved in the debate going on over at the Atlantic over alternative medicine, spawned by an article by David Freedman. I first wrote about the article here, with a follow up here. Orac has written a series of articles about it as well, and we covered it on Science-Based Medicine.

The Atlantic has also hosted an ongoing debate on the topic. Apparently at the Atlantic they feel that a fair debate is to have six prominent advocates on one side, along with the original author of the article, against a lone token skeptic on the other side (Steve Salzberg). Well, at least they are not revealing any bias. At the urging of Salzberg they did add a second token skeptic, David Colquhoun.

The debate, such as it is, at least reveals the current rhetorical tactics of the CAM proponents. They can be summarized largely as – we know that CAM modalities don’t work, but we’re nice and they will give you a good placebo effect. Plus science-based medicine isn’t perfect (shocker), so (false dichotomy) we offer an alternative. CAM proponents further try to take as much credit as they can for just good medical practice and some science based modalities, like nutrition, exercise, and good communication skills.

This latter strategy is all about the bait and switch – come for the good communication, stay for the abject pseudoscience. Or (here’s a radical idea) we could just continue our efforts to improve the practice of medicine without ejecting all science and reason in the process.

All of this is standard CAM fair, and no surprise. But perhaps the most disappointing aspect of the whole debate has been the reaction of the original author, David Freedman. He appears to have been stung by the (quite reasonable) criticism of his piece, and now gives every indication of circling the wagons. He is trying a number of logically-flawed gambits, all familiar to skeptics.

His latest rebuttal it titled: What’s Eating the Small, Loud Band of Alt-Med Critics? The article is an attempt to defend his position, which he does while ignoring most of our actual criticism. He also does his best to dismiss us out of hand – starting right with the framing in the headline (which, even if he did not write it, accurately reflects the article itself).

Here is a paraphrase of his article – “Don’t bother listening to these guys. There’s like four of them, and they are just angry and closed minded.”  Freedman would have you believe that he marshaled all of his journalistic skills to track down the only four CAM critics in the world. First, I have already dealt with this false impression in my second article on this debate – and Freedman has chosen to ignore my refutation. (He can’t pretend not to know my blog exists, as he left a comment on the first article.)

But most importantly – this is a gross misrepresentation. Really, Freedman should be ashamed of that assertion. Just checking the various authors on the SBM website comes up with many other names. Or, he could have gone to the Institute for Science in Medicine website and looked at our list of Fellows – we are up to 54 (mostly, but not all, MDs). These are all professionals who are as dedicated to the defense of science in medicine against the forces of pseudoscience as the four that Freedman recognizes. If Freedman could not find the ISM himself, he could have asked me for references while interviewing me for the article. Clearly he wasn’t interested.

And there are many others, such as Ben Goldacre, who Freedman likely knows about as Ben was suggested as a possible second token skeptic for the Atlantic “debate.” Ben is internationally known for his criticism of CAM and other pseudoscience. Some of his fellow journalists get it too – like Simon Singh.

Freedman also ignored the arguments I put forward to put these numbers into context. Namely that most physicians do not understand the nature of CAM. They buy into the bait and switch deception, because they never cared enough to look into more deeply. When they are made aware – they are as outraged as the rest of us at the infiltration of pseudoscience into medicine.

Freedman also tries to frame our position as hating CAM, as if we are protectionist and irrational. Rather, our stated position is that we are pro-science-based medicine. We advocate the application of a single science-based standard in health care, and we are concerned by the deception, illogic, and abuse of science that CAM promoters use to insinuate their practices into mainstream medicine. They are trying to establish a double standard for their preferred modalities – and that’s what we oppose.

All of this is just an elaborate argument from authority, which Freedman acknowledges. It reveals, however, his rhetorical tactics – portray his critics as on the outside and closed-minded. In a comment to Orac’s most recent blog post he even takes this gambit one step further. He writes in part:

I characterize religion-like thinking as being absolutely certain that one has hit on pure truth, that the evidence supporting it is perfectly solid, that the evidence that might be held to refute it is weak or flawed, that anyone who disagrees simply doesn’t get it or is highly biased, and that any arguments or evidence presented to counter one’s beliefs must be (supposedly) demolished or ignored so that no trace remains that might prompt reconsideration in the least of any aspect of one’s beliefs.

Obviously determining who should be labeled a scienceologist is a subjective affair, but here’s one little field test that I find helpful: When a proponent of one particular view or theory in a presumably scientific debate consistently fails to yield any ground on any points, or concede any possible truths to any aspect of the opponent’s views, I fear I’m dealing with scienceology. After all, we live in a complex world, and the chances that one is right about all aspects of any non-trivial issue are minute. Only religion-like faith invites and sustains belief that one has it completely right in every way, or so I would argue. Succumbing to scienceology doesn’t necessarily mean one is wrong, but in my opinion it means if one is right, one is just lucky, because one has closed one’s mind to all routes to discovery of being wrong.

I most definitely do not feel you folks are engaging in scientism in criticizing my article. I heartily agree with you that science should, at least in principle, be able to settle the question of whether there are measurable patient benefits to alternative medicine when compared to mainstream medicine, even if the core treatments of alternative medicine work no better than placebo.

Freedman is arguing that we are all guilty of “scienceology” – holding to our position with religious-like zeal. This is a strategy that should be familiar to most skeptics. PZ Myers, who is not a physician but who is a good skeptic, picked it up right away. In his review he wrote:

The way it did this was devious, and reminded me so much of creationist tactics. First, it declares that “mainstream medicine itself is failing”; it doesn’t really have any evidence of this, it just declares that modern medicine is built around the infectious disease model, and that it hasn’t solved all health problems. Familiar stuff, hey?

The creationist analogy is sound. Freedman is taking the false balance approach above – the truth must be somewhere in the middle of these two sides. But this is not always the case. Pair any creationist against a mainstream evolutionary biologist and you will find that the biologist is unyielding, unwilling to concede any points to the creationist. The reason – creationism is ideological BS. It is sophisticated nonsense, but it is pseudoscience down to the core. However, this allows creationists to portray defenders of evolution as being closed-minded, intellectual thugs, and opposed to academic freedom and open debate.  In short Freedman’s rule of thumb utterly fails when applied to pseudoscience.

We see this over and over again. Pseudoscientists make outrageously unscientific claims, and then when defenders of science are outraged they are portrayed as extremists for their outrage. Journalists often fall for this (when balance becomes false balance), and Freedman is no exception.

Further, we collectively have written thousands of articles explaining in great detail why the claims of the CAM crowd are simply wrong. We are not being dismissive or closed – we are carefully articulating a persuasive position. Freedman has clearly not availed himself of this.  (I am not saying he should have read it all, but a sampling would be nice. Or at least recognize that our body of work exists, and perhaps be a bit more humble in your conclusions, if you are not willing to delve deeply into our arguments.)

Freedman is still not listening. He keeps repeating his basic premises, as if we have not dealt with them already, and pretending like we haven’t. Yes, we agree that CAM works no better than placebos. Yes, we agree that there are limitations to mainstream medicine. But no, we do not agree that CAM practitioners are better at instilling good lifestyle choices than MDs. There is no compelling evidence for this. And no, we do not agree that placebo effects are worth it.

Freedman also acts as if these are the only points relevant to the discussion. The problem with Freedman’s reporting is what he did not discuss. The harm that is done by unscientific practices is being increasingly documented. I think we have made (many times) a cogent argument that using pseudoscience to get a placebo effect, and sometimes wrapping it in some common sense advice that you can get from any competent practitioner, is a huge net negative, not a net positive as Freedman argues.

But Freedman continues to insist that his position is rock solid and unassailed. He should go back and read his definition of “scienceology” again.

Finally – what exactly is Freedman proposing? He has come to the dubious conclusion that CAM is worthwhile, even if just for the placebo effect. And therefore what? Does he think we should prescribe homeopathic potions to patients, even though they are just water? Does he think we should stick needles into non-existent acupuncture points, even though the evidence shows poking the skin with toothpicks is just as effective? Should insurance pay to have nurses wave their hands over patients prior to going into surgery in order to fluff up their “human energy field?”

What, exactly, does he imagine should be happening? And what should we tell patients? Should we tell them that these interventions are just placebos? Or should we instill in them a belief in magic and pseudoscience, in order to maximize the placebo effect (although the evidence does not support this conclusion). How would we regulate CAM? If scientific evidence is no longer the standard, then anything goes – we already have ample evidence for this in the CAM and supplement industries. How do we keep out the cranks and exploiters? Paul Krugman put it very succinctly when he wrote (in the context of economics, but it still applies), “When the public believes in magic, it’s springtime for charlatans.”

Unless Freedman and others who support his position can articulate exactly what kind of medical system they envision that incorporates CAM, I see no reason to take their position seriously. It’s easy to criticize an existing system, like mainstream medicine. It’s more difficult to propose workable improvements. One might say that we should take advantage of the alleged benefits of CAM (lifestyle improvements) while fixing the pseudoscience. But I submit it would be far easier to fix the problems in mainstream medicine, than to try to fix the rotten-to-the-core pseudoscience problems in CAM. Freedman’s cure is far worse than the apparent disease.

Mainstream medicine at least has a built-in system for self-correction (science). Show us a better way with reliable evidence, and we will change our practice. CAM proponents, on the other hand, display a clear history of trying to fit the evidence to their practice, rather than their practice to the evidence. When the evidence does not fit – they dismiss it, and then try desperately to change the rules of evidence. They seek the evidence that is most likely to support what they already want to believe – like their current advocacy for using pragmatic studies (unblinded studies) instead of double-blind efficacy trials to assess outcomes.

The bottom line is that Freedman got his bottom line wrong. He appears to have engaged in a process of confirmation bias – before he interviewed me he had a clear idea of the article he was going to write. The article was framed by the questions he asked and the people he spoke to, but even more by the questions he didn’t ask and the people he didn’t speak to. In my opinion, it was a journalistic fail.

All that would be forgivable – it’s a complex topic shrouded with sophisticated deception on the part of proponents. Freedman fell for the smoke and mirrors. What matters most, however, is what you do after the article is out there in the public. Christopher Hitchens told me in an interview that after he publishes an article on a topic, then all the people that he should have interviewed in the first place come out of the wood work. The most productive research is done after the first article is published and the ideas are out there.

Freedman should consider the publication of his Atlantic article the beginning of his journey to truly understand this topic, not the conclusion. We in the science-based medicine community are trying to engage with his ideas (if he can look past the occasional snarkiness). Our style is unrestrained criticism (much like how science itself works). We don’t pull our punches. But Freedman seems like a big boy. I would like to see him try to actually answer my criticisms, rather than continue to hide behind his original premises.

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