Hornet’s nest


Thanks to commenter Pat Sullivan, Jr. in the “rant on clinical trials”:http://www.randomjohn.info/wordpress/2005/09/15/ranting-and-raving-again-about-healthcare-and-the-magical-clinical-trial/, I’ve finally found out who “Orac”:http://oracknows.blogspot.com is, and it seems I’ve stumbled into a bit of a hornet’s nest. Quite frankly, though I’ve viewed the Quackbusters for a long time as an example of the worst that science can produce (given that, in addition to science and quality of life improvements, science generates territorialism, credentialism, and a whole host of other things that are neither positive nor “scientific”), I never thought I’d be tangling with one of them. But you know what, if this continues I’m not going to back down, and here’s why.

Exposing medical fraud or any type of fraud is a noble cause. I’m glad there are people who care about people enough to spend their precious time finding those who, for the sake of only making money, will sell worthless or harmful products.

The problem comes in when “quack-busting” gets confused with “my healthcare system will kick your healthcare system’s ass.” Further confounding with a particular virulent form of “skepticism”:http://www.skepdic.com has occurred, at least in D — er, Orac’s case. (Roll your mouse over some of the links at one of “Dav…, er, Orac’s responses”:http://oracknows.blogspot.com/2005/09/little-criticism-directed-oracs-way.html to my post about clinical trials. Try the “confirmation bias” and “selective thinking” links.)

Let’s break this down a little bit further. There are some assumptions in drug development that are very necessary:

_If it isn’t documented, it isn’t true_

This is fine for the regulatory where you’re essentially trying to prove beyond a shadow of a doubt that your compound works, and that it isn’t a fluke, and that thirty scientists, doctors, and biostatisticians are going to sift through your work with a fine tooth comb to make sure you’re not out of line.

What it’s not fine for is defining what truth is. For most of us, 99.9% of life is not a regulatory environment. Truths are not documented, and are probably not documentable. Who cares, anyway, besides the skepdics? (To be distinguished from ordinary skeptics.) Aristotlean logic is not the only path to truth, and not all destinations of Aristotlean logic are truth. The results of logic are at most as good as the assumptions (and there are _always_ assumptions).

_The placebo effect has no clinical value_

Again, this is a fine assumption for a regulatory environment, where you don’t want someone to claim their $3 a pop pills work when an inactive pill work just as well. Out in the real world, (oh, and by the way, doctors use the placebo effect _all the time_ in the real world), perhaps we don’t use the placebo effect skillfully enough. The placebo effect can be thought of as simply living in a healthy way — diet, exercise, thoughts, attitudes about life, seeking out situations that fulfill and support health. The sugar pill that we’ve all heard of is a part of the placebo effect, and most “sources”:http://en.wikipedia.org/wiki/Placebo_effect “stop”:http://skepdic.com/placebo.html “there”:http://pubs.acs.org/hotartcl/mdd/99/aug/mysterious.html. (BTW, I actually found skepdic.com’s entry somewhat helpful on this, when I keep the scope and intent of the article in mind.)

And what about this “all the time in the real world.” Have you ever seen a cancer doctor treat a patient? A lot of times they’ll, upon entry, exhibit a more sanguine approach than otherwise may be warranted. They are using the principles of the placebo effect. Or the pediatrician who gives antibiotics for viral infections or recurrent ear infections, and so forth.

Every applies the principles of the placebo effect unknowingly. The same is true for the placebo’s evil twin, the “nocebo effect”:http://www.washingtonpost.com/ac2/wp-dyn/A2709-2002Apr29. (Read about the study between aspirin and another blood thinner. It’s very enlightening.) The stories of the nocebo effect warn us that these principles are not to be taken lightly, and, since we’re not in a regulatory environment most of the time, we’re free to examine our own application of the placebo effect.

There are more, but I want to move on to some assumptions that are not so necessary:

_Your experience doesn’t matter in science_

Read about it “here”:http://skepdic.com/pragmatic.html, under the fancified name “pragmatic fallacy.” The confirmation bias discussion reinforces this. While it is fallacious to assume that what works for me works for you or anyone else, it’s equally fallacious to assume that what doesn’t work for me will not work for you. Things get even murkier when we start talking about what is True. Few things are True for All People — a few principles of physics and chemistry that seem to describe how the stuff of our existence works. (And who knows, maybe they’ll be false tomorrow, the way that Newtonian mechanics became “false” when Einstein performed and published his work on relativity.) Does this mean that we can ignore everything else? Absolutely not. Things that are not on the blessed list of Truths for All People are just as real as those things that are. Put another way, just because something is not currently amenable to scientific inquiry doesn’t mean it’s untrue, ignorable, or unreal.

_If it ain’t Western medicine, it’s quackery_

This is the interpretation I get out of these quackbuster sites. Even the “Wikipedia entry”:http://en.wikipedia.org/wiki/Quackery is “disputed”:http://en.wikipedia.org/wiki/Talk:Quackery, in part because of the seeming huge overlap between the discussion of the practice of alternative medicine and the deliberate theft of money through the use of deception. Rarely will you see a quackbuster praise a study on alternative medicine unless they show the “superiority” of a conventional treatment.

_The coevolution of methodology and knowledge_

This is topic which I was reluctant to bring up, but I think it’s important. I’m reluctant to bring it up because I haven’t found a way to adequately express my misgivings on the subject. It goes something like this: our pharmaceutical process is a system, and that system includes the methodology designed to sift through and confirm the safety/efficacy of our pharmaceutical compound. Alternative medicine practices, such as homeopathy (alternative medicine really isn’t a system in itself, but consists of many such different systems), have their own theories and practices which support the system. Whether alternative medicine systems might be found lacking by the gold standard randomized controlled trial (RCT) is one matter, but the fact remains that the methodology supports one particular system the best. This isn’t to say that the RCT should be abandoned outside of pharmaceuticals (or other systems, such as modern agriculture, that have co-evolved with methodology), but that we should examine the “inherent biases”:http://www.patsullivan.com/blog/2005/09/autismmercury_c.html in systematic study[1].

And here, the inherent bias is in failing to critically examine the _system_ of pharmaceutical production (and, more generally, production of science). Just because this system has brought us antibiotics doesn’t mean that products not discovered or even refused by the system cannot assist in healing. It also does not mean that other systems cannot produce quality healing products. This may make Orac barf, but that’s probably for the best.

At any rate, we should thank those people who honestly try to protect us from scams. And we should be critical of those who take it way too far, or who use this quackbusting cause to assert their own beliefs about the world.

fn1. This article is ostensibly on the connections between mercury and autism, but it has some interesting findings on the connections between RCT(randomized controlled trial)s and funding, selection bias, and other definitely non-scientific factors.

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2 Responses

  1. Great commentary and explanation on what I would entitle, “when ‘skepticism’ becomes your religion.” Yes, healthy skepticism is healthy. Realistically, people *already* have their guard up for scams (aside from those winning Darwin awards, of which I am skeptical even exist. 😉

    I know there are PLENTY of people, products, websites in my industry (health foods and dietary supplements) to be skeptical of. Even though I’ve only been in the industry for about a year, I’ve had a view to the inside of it and it can be pretty ugly.

    THEREFORE, we (Jigsaw Health) go out of our way to be as open and honest — and thus, credible — to our customers. But if you set expectations properly and have quality products, it’s not actually that hard to create a great customer experience (which I believe is our own form of “placebo effect”).

    However, we/I do get a few emails a month from customers wanting to return our products because they took them and they didn’t “work” (ie. they didn’t feel a difference or feel better.)

    Here is an actual reply I sent to a customer last Saturday who recently puchased products and wanted a refund:

    “[Name removed], thank you for contacting me and allowing us to make things right for you. We will gladly refund $X [dollar amount removed]. Karen [Customer Svc Manager] will take care of the particulars on Monday for you.

    Though it would be nice, it is impractical for me to expect all of our products to work 100% of the time for everyone. Still, I’m always disappointed when a customer doesn’t have a great experience because I know that they still have to find something to address their chronic condition(s).”

    That is how I honestly feel. And that’s about as good an experience as I can give a customer. Give them enough confidence that maybe your stuff will help them feel better. If it doesn’t, refund their money.

  2. […] Pat Sullivan, Jr. discusses in some recent posts the roles of different types of medical evidence. First, let me get an issue out of the way concerning the definition of “anecdote,” since it seems to get in the way. From Sullivan’s entry: […]

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