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.

10 responses so far