Over my nearly six years of blogging, I’ve become known as a staunch advocate of science- and evidence-based medicine, both in the guise going under my long-used pseudonym “Orac” and under my real name. And so I am, which is why certain varieties of predictable attacks on science-based medicine (SBM) annoy me. Usually, they come down to appeals to other ways of knowing, rants against “arrogance,” or tu quoque arguments trying to claim that SBM is as bad as whatever woo I happen to be criticizing at the time. Actually, strike that. The latter complaint often tries to argue that SBM is actually worse than various non-science-based medical systems because (or so it is alleged) a combination of pharma corruption and an excessively dismissive attitude towards anything that is not science lead (or so it is alleged) to, well, I’m not sure what. Bad care? Bad medicine? Or are we advocates of SBM just plain mean, nasty, and arrogant to have the temerity to criticize the touchy-feelies that advocates of “complementary and alternative medicine” (CAM)? I’m never quite sure.
So it is with the latest broadside against SBM that I’ve become aware of, this time courtesy of Dr. Marya Zilberberg, who apparently doesn’t like what she describes as the Paternalism of Science-Based Medicine (also crossposted to BMJ doc2doc). Yes, it’s like waving the proverbial red cape in front of the charging bull. When I see so many straw men concentrated in such a small area, it’s very hard for me to resist pulling out my handy flamethrower of science and sarcasm and spraying away, much as the Marines did to Japanese pillboxes in the Pacific Theater during World War II. No doubt that makes me a nasty, reductionistic, paternalistic, allopathically vicious robot using the jackboot of science to crush all the crunchy, squishy feelie stuff out of medicine, thus rendering it devoid of any trace of human caring and emotion. Well, not really, but that’s how I’m frequently portrayed. In any case, get a load of how Dr. Zilberberg starts out her broadside against SBM:
The argument goes like this: We who practice science-based medicine are the only ones that are correct in our approach because everything we do comes from a scientifically derived pool of evidence. Anything else is quackery, also referred to as “woo”, which includes all modalities that do not fall in line with this EBM paradigm. They rail equally against healing crystal charlatanism, acupuncture, Reiki, and “anti-vaxers”, lumping them all into the ignorant masses that dare go against what we “know” at their own and societal peril. They maintain that there is not room for anything in healthcare other than the “proven” scientific interventions.
So, if they advocate for science as the prevailing force in medicine, why should I, a firm believer in evidence as the backbone of healthcare, object?
Why, indeed? Of course, this sort of argument is very similar to the “I believe in science, but…,” where the “but” is far more powerful than any belief in science expressed. Dr. Zilberberg says she believes in evidence as the backbone of healthcare and then in this post and another post entitled The reality of science-based medicine, goes to great lengths to show that, when the rubber hits the road, she does not really mean what she says. In essence, the “but” overwhelms everything else, blasting out gaseous emanations much like its real-life anatomic homophone does. Dr. Zilberberg builds an elaborate straw man, only to tear it down with extreme gusto.
First off, those of us who advocate SBM do not argue that we are the only ones who are correct because everything we do comes from a scientifically derived pool of evidence. That is a mischaracterization of what SBM is. Rather, as I’ve discussed many times, there’s a reason we don’t refer to SBM as “science” but rather science-based medicine because so much of medicine can’t ever be made perfectly scientific. However, we do argue that what we do as physicians should be based in science, hence the name science-based medicine. Yet, the bulk of Dr. Zilberberg’s two posts seem to argue that what SBM is is doing nothing in medicine but pure science, much like Sheldon Cooper or Mr. Spock might do. Or so Dr. Zilberberg seems to imagine.
But what do I know? I’m just one of those nasty, reductionistic, “Western” scientists who have the temerity to insist on evidence and science to support the interventions that we physicians use. I know, I know, it’s a difficult and painful concept to grasp, and I’m just so incredibly “arrogant” to assert such things, but there you go. I don’t think that doctors should be offering reiki, for example, because there is no evidence that reiki is anything other than faith healing. The only difference between reiki and faith healing is that reiki uses as its basis Eastern mysticism rather than Christian beliefs. People can decide they want faith healing if they wish, but for a physician to advocate faith healing is a profound betrayal of our profession because we as physicians are supposed to advocate treatments that–oh, you know–actually work and not mystically inspired pseudoscience.
Dr. Ziberberg also goes wrong when she claims that we lump all of these pseudoscientific or anti-scientific treatment modalities into some sort of rant against the “ignorant masses that dare go against what we ‘know.'” For instance, I definitely treat these modalities differently depending on their potential to cause harm to others. The reason I “take no prisoners” when it comes ot the anti-vaccine movement is because the anti-vaccine movement endangers far more than just the children who go unvaccinated because their parents ascribe all sorts of evils to vaccines that are not supported by science. It endangers all children who come into contact with unvaccinated children.
Be that as it may, Dr. Ziberberg’s attitude appears to be encapsulated in this next passage:
First of all, it is my belief that all interventions should be approached with equanimity, if not equipoise. Although I am quite dubious that either healing crystals or Reiki can produce actual results, I do not want to confuse the absence of any evidence to this effect with the evidence of absence of the effect. Although I am not that interested in allocating resources to studying these fields, it would be paternalistic of me to bar their further investigation.
Wow. A straw man that massive, if set on fire in, for example, New York, could be easily seen in Los Angeles. It would take a nuclear reaction to get such a pyre of burning straw men started. No advocates of SBM say that we should “bar further research” into healing crystals, reiki, or whatever. We do, however, point out that prior plausibility would strongly suggest that additional research into healing crystals, reiki, and especially homeopathy would be a waste of money. And, yes, we do suggest that the National Center for Complementary and Alternative Medicine (NCCAM) should not be funding these sorts of studies–indeed, that it shouldn’t exist at all! The reason, of course, is because we reject the term “alternative” medicine. There should be no such thing. There is medicine that works, medicine that has been shown not to work, and medicine where we don’t know. “Alternative” medicine is made up almost completely of the latter two categories. In any case, I would submit to Dr. Ziblerberg that suggesting that the federal government should not be funding studies into pseudoscience is not the same thing as advocating “barring their further investigation.” If someone like, say, Dr. Zilberberg, wants to fund research into woo like reiki, healing crystals, homeopathy, acupuncture, or the healing power of prayer, I say to her: Knock yourself out. Just don’t ask me to pay for this stuff through my tax dollars, and don’t expect me to pay for it through my health insurance policies. Of course, Dr. Zilberberg’s assertion that “all inteventions should be approached with equaniminity, if not equipoise” is utter nonsense, the purest expression of the wrong-headed application of postmodernism to science, where science is “just another narrative” and all “narratives” should be considered equally valid regardless of evidence. Making such a claim is nothing more than being so open-minded that your brains fall out.
Worse, it is a profound betrayal of medical ethics to view “all interventions should be treated with equaniminity, if not equipoise.” Not all interventions are worthy of being treated that way, and we can make preliminary judgments on such modalities on the basis of basic science alone. Consider homeopathy, for example. I realize that it’s one of my favorite examples, but that’s just because it so starkly illustrates the principles of plausibility and prior probability. For homeopathy to work, many well-established laws and theories of physics, chemistry, and biology, science that has been validated over hundreds of years, would have to be not just wrong, but spectacularly wrong. While it is possible that scientists could be spectacularly wrong about so many areas of well-studied science, it is exceedingly unlikely, making homeopathy exceedingly unlikely to be anything more than water acting as a placebo. There is no reasonable rationale to treat homeopathy with “equanimity, if not equipoise” because most homeopathic remedies, particularly those diluted beyond around 12C, are incredibly unlikely to contain even a single molecule of active ingredient. If CAM advocates want to believe that somehow water remembers the good stuff that’s been in it and forgets, as Tim Minchin so famously put it, all the poo, that’s fine for them, but don’t expect scientists to take such claims seriously without evidence of sufficient quantity and quality to mount a reasonable challenge to the hundreds of years of science that says homeopathy can’t work. The same holds true for reiki, therapeutic touch, and many other highly implausible CAM modalities.
Dr. Zilberberg continues:
So the society can decide what it wants to do with them, and in the meantime every individual can make her/his own choice whether to spend their money on them. Interventions in the broad area of traditional Chinese medicine (TCM), including herbs and acupuncture, elicit less visceral aversion in me, and may be shown down the road to have desired health effects, though their study may not be amenable to our current methodologies. Again, at this time, if an individual wants to try them out, they should be keenly aware of how little we explicitly understand about them, including both their risks and potential benefits.
Ah, yes, where have we seen this argument before? Basically, this is the old claim that science can’t study my woo (“their study may not be amenable to our current methodologies). In other words, its pure special pleading. From my perspective, special pleading, too, is utter nonsense. Our methodologies are more than adequate to study CAM, particularly herbal remedies and traditional Chinese medicine (TCM). The problem, when it comes to apologists for woo, is that science doesn’t show what they want it to show. Science conclusively shows that, for instance, reiki is nothing more than placebo, that acupuncture is no more than placebo, that homeopathy is no more than placebo. That’s why reiki masters, homeopaths, and acupuncturists don’t like it, and that’s why they use special pleading to argue that their woo is actually just ducky, if only scientists would stop being so damned judgmental.
Of course, science is supposed to be judgmental, at least when it comes to distinguishing good science from pseudoscience. Or not, according to Dr. Zilberberg in another post entitled The reality of science-based medicine:
Now, let’s get on to “proof” in science-based medicine. As you well know, while we do have evidence for efficacy and safety of some modalities, many are grandfathered without any science. Even those that are shown to have acceptable efficacy and safety profiles as mandated by the FDA, are arguably (and many do argue) not all that. There is an important concept in clinical science of heterogeneous response to treatment, HTE, which I have addressed extensively on my blog. I did not make it up, it is very real, and it is this phenomenon that makes it difficult to predict how an individual will respond to a particular intervention. This confounds much of what we think is God’s own word on what is supposed to work in allopathic medicine.
Ah, yes. Here’s another dubious argument favored by CAM advocates, the tu quoque combined with the Nirvana fallacy. Basically, it’s “nyah, nyah, SBM has problems,” as if those problems somehow validated CAM modalities and other therapies preferred by woo-meisters. It’s also the Nirvana fallacy (a.k.a. the fallacy of the perfect solution) saying that if something (like SBM) is imperfect it must be total crap. I love binary thinking like that for what it tells about the views of the person using it, who virtually never hold the woo they defend to the same standards. Only SBM is total crap if it isn’t perfect, and that view allows its knee-jerk critics to dismiss it while embracing modalities whose evidence problems beggar the imagination compared to SBM. Dr. Zilberberg also seems to think that SBM doesn’t consider heterogenous responses to treatment as though she’s the only one who considers the fact that not all patients respond to therapies in the same way, to which I respond: “Well, duh!” I also wonder what all those statistical models we apply to clinical trial analysis are for. Oh, wait, I know. They were developed to account for variability in disease progression and response to treatment.
But let’s get back to the original post. I mentioned the other post only to show that apparently these attacks on SBM represent a pattern. Perhaps the most disturbing passage in this whole broadside against SBM is this one:
The vaccine debate is yet another completely different issue altogether. In our privileged society the specter of infectious epidemics is for the most part but a distant memory, yet our concerns for the safety of our children combined with a rampant, albeit not altogether unjustified, distrust of the pharmaceutical industry and the government, have colluded to promote a biased yet durable suite of misinformation about the risk-benefit profile of vaccinations. Some of this prevailing sentiment may be because, in my opinion, we have focused on the wrong outcomes (e.g., the economics rather than morbidity associated with chicken pox), or that we have overstated what we really know and understand, at the risk of sounding too confident and therefore not trustworthy partners in this important area of public health. But these are just my own speculations.
I’m afraid in this case that Dr. Zilberberg’s speculations are a load of fetid dingo’s kidneys. I know, I know, I’m being all mean and “judgmental,” but when it comes to the anti-vaccine movement the pseudoscience is so think and the potential for harm so great that I have a hard time being polite. The anti-vaccine movement is arguably the greatest threat to children; yet Dr. Zilberberg disturbingly poo-poos it and shows evidence that she is in fact sympathetic to antivaccine sentiments, as demonstrated by her swipes at the pharmaceutical industry in the context of criticizing vaccine defenders as being “too confident.” She then drops this on her readers:
My intent is not to belittle what clinical science has and continues to bring to the society.
Yeah, right. Dr. Zilberberg says this after lambasting SBM for being paternalistic and appealing to other ways of knowing to try to make SBM seem hopelessly close-minded when it comes to woo that for which she seems to have a penchant, given that she mentioned them so many times (reiki, healing crystals, etc.). But let’s get to the money quote:
After all, thanks to it, we have a much better understanding of many illnesses now, and we can even take credit for effecting better outcomes for many a sick individual. At the same time we really need to sow humbleness in place of arrogance in all the places where the latter runs rampant. Philosophers of science have understood for decades that there really is no universal truth, and everything we think we know we understand through the prism of our collective human and individual experience. So, instead of wasting time on throwing boulders at our competition, why not take a closer look at the material that our house is made of. Dropping our inveterate paternalism in favor of being truthful about the degree of our uncertainty may make us look more human and fallible, yes. At the same time, it may show our patients and the public at large that we are on the same side. Though this is a risk, it is a necessary one to repair our rapidly crumbling therapeutic relationship. Admitting to not knowing is not only not a weakness, it is the only way to scientific progress.
Quite honestly, after reading this, I got that uncomfortable feeling in the pit of my stomach that signals I’d better stay near the porcelain god. Seriously. Where on earth Dr. Zilberberg gets the idea that those of us who support SBM think that we know everything and would not admit to patients when we don’t know something (at least, any more than any other physician would), I don’t know. In fact, SBM demands far more than what what preceded evidence- and science-based medicine, something I like to call tradition-based or dogma-based medicine. That’s because we have to discuss the actual evidence supporting our decisions for individual patients and our assessment of how likely it is that our intervention will work.
When it comes right down to it, to me Dr. Zilberberg’s attitudes are profoundly anti-science, whether she realizes it or not. (No doubt she does not.) She criticizes virtually everything about SBM and then elevates pseudoscience to the same level as science in a truly postmodern fashion (“Philosophers of science have understood for decades that there is no universial truth, and everything we think we know we understand through the prism of our collective human and individual experience”? That’s as concise a statement of postmodernism applied to science as I’ve seen in a long time.) Worse, like all good postmodernists, Dr. Zilberberg views any attempt to suggest that there might be an objective reality that can be described and defined by science as “paternalistic.” It’s The Man keeping other points of view down, maaaaan! We can’t have that, now, can we?
Unfortunately, Dr. Zilberberg seems to be confusing legitimate authority with excessive paternalism. Whether she’s doing it intentionally or unintentionally, I don’t know, but I do know that she’s doing it. Here’s a hint: Sometimes there is legitimate authority. I know, I know, it’s hard to believe, but legitimate authority exists. That does not necessarily make it “paternalism.” Besides, if you want paternalism, check out alt-med! Sometimes we really do know what the best course of action is. That’s not necessarily “paternalism” or “dogma.” It’s just what the evidence strongly suggests. Moreover, the days of purely paternalistic medicine have long passed. Gone are the visions of doctors from the 1940s in which the doctor told the husband but not the wife that she had incurable cancer or where the doctor told patients to do things just because of his authority. (Female physicians were quite rare back then.) In fact, the decline of paternalism correlates very nicely with the rise of EBM and SBM. True, that correlation does not necessarily equal causation, but it does suggest that Dr. Zilberberg’s cry of “paternalism!” against SBM is exaggerated at the very least.
Her protestations otherwise notwithstanding, Dr. Zilberberg seems to think that SBM is so hopelessly flawed that we might as well all throw up our hands and become reiki masters. In reality, SBM is our best currently existing tool to bring the best care to our patients, and it is important that we know the limitations of this tool. Contrary to what CAM advocates claim, there currently is no better tool. If there were, and it could be demonstrated conclusively to be superior, I’d happily switch to using it, and so would virtually all doctors with whom I associate.
To paraphrase Winston Churchill’s famous speech, many forms of medicine have been tried and will be tried in this world of sin and woe. No one (and certainly not I) pretends that SBM is perfect or all-wise. Indeed, it has been said (most often by me) that SBM is the worst form of medicine except all those other forms that have been tried from time to time. I add to this my own little challenge: Got a better system than SBM? Show me! Prove that it’s better! In the meantime, I share Steve Novella’s view that I really, really wish people who criticize SBM would do so based on real shortcomings rather than on logical fallacies and exaggerations.