Evidence-based medicine: More than a “coin flip”

One characteristic of cranks, quacks, and pseudoscience boosters is a love-hate relationship with science. They desperately crave the respectability and validation that science confers. In the case of medicine, they want to be seen as evidence- and science-based. On the other hand, they hate science because it just won’t given them what they want: Confirmation and validation. The reasons, of course, are obvious; their preferred ideas about disease and modalities to treat it are not rooted in science. Rather, they’re usually based in either prescientific concepts of how the human body works and how disease attacks it (i.e., vitalism or miasmas), or they are based in completely unscientific belief systems, or both. It’s not surprising, then, that science either tells them that their ideas are nonsense right from the start (i.e., for homeopathy or distance healing) or finds when it tests treatments based on those ideas that they do not perform better than placebo.

All of this explains the propensity of quacks and apologists for quackery to attack medical science, to try to convince people that it is unreliable or even dangerous. We see this when people like Gary Null try to convince you that medicine kills 600,000 people a year in the US, a number, which, if true, would make medicine roughly tied with heart disease as the number one cause of death, if not the number one cause of death. It would also mean that more than one in five people in the US who die each year die due to medical treatment. It’s utter nonsense, but it feeds a narrative in which medicine is not just ineffective but downright dangerous in comparison to, of course, the lovely “natural” cures that are much safe. The unspoken and unadmitted reason that such treatments are often safer is because they are also ineffective placebo medicine, the way homeopathy is water, but that is never mentioned.

Such were my thoughts as I encountered yet another example of this sort of demonization of medicine. It’s a post by Sayer Ji. We’ve met Ji before when he tried to argue that vaccines are transhumanism that somehow subverts evolution and attacked the Bill and Melinda Gates Foundation. This time around, he’s trying to convince you that evidence-based medicine is completely uncertain, even going so far as to entitle his post “Evidence-based medicine”: A coin’s flip of certainty. It’s a veritable cornucopia of antiscience fallacies aimed at medical science. In fact, as I read Ji’s little screed, I began to get the image of Mike Adams. There is more than a passing resemblance to Ji’s bad science and misunderstanding of evidence-based medicine and Mike Adams’, beginning with the attempt to convince readers that most research is not just false, but patently false:

The very life’s blood of ‘evidence-based’ medicine — peer-reviewed and published clinical research results – which legitimizes the entire infrastructure and superstructure upon which conventional medical knowledge and practice is erected, has been revealed as mostly and patently false.

Case in point: in a 2005 essay, “Why Most Published Research Findings are False,” and which is the most downloaded document of all time on PLoS, the Public Library of Medicine’s peer-reviewed, open access journal, John P. A Ioannidis explains in detail how “It can be proven that most claimed research findings are false.” And that “for many current scientific fields, claimed research findings may often be simply accurate measures of the prevailing bias.”

The Atlantic published a piece on Ioannidis’ work, back in 2010, titled “Lies, Damned Lies, and Medical Science,” well worth reading, and which opened with “Much of what medical researchers conclude in their studies is misleading, exaggerated, or flat-out wrong. So why are doctors – to a striking extent – still drawing upon misinformation in their everyday practice?”

Cranks love John Ioannidis, and so do I. Of course, we love Ioannidis for different reasons. I love Ioannidis’ work because it demonstrates very clearly the limitations of clinical trials and suggests how we can overcome them. Cranks, on the other hand, love Ioannidis because he gives them material with which to attack evidence- and science-based medicine. Unfortunately, they completely don’t understand Ioannidis, who is not at all saying that EBM is no better than a coin flip as to whether it’s accurate or not. What he is saying is that you can’t look at just individual studies, because any single study is more likely to be wrong than it is to be correct. However, the preponderance of studies will over time converge on effective treatments.

Ioannidis is also most definitely not friendly to cranks, contrary to what Ji thinks. As I’ve described before, the problem of false positive studies becomes more serious the lower the prior plausibility of the hypothesis being tested. That’s why testing something like homeopathy, which involves diluting substances to the point where it is incredibly unlikely that even a single molecule remains, can produce so many seemingly “positive” studies, even though science tells us that what is being tested is nothing but water. Moreover, Ioannidis’ observation that perhaps 1/3 of highly cited papers ultimately turn out to be wrong indicates that, contrary to what the cranks tell us, science really is self-correcting and will be more likely to get it right over time, discarding false hypotheses and dead ends. It is true that the process is messier than we might like, that it often takes longer than we might like, and that it produces more dead ends than we might like, but science also demonstrably works better than anything the quacks can come up with. It also eventually unloads and abandons therapies demonstrated to be ineffective, something “alternative medicine” virtually never does.

Oddly enough, Ji almost starts to make sense at one point in a criticism of the hierarchy of evidence in EBM, something I’ve criticized myself from time to time. Almost:

Evidence-based medicine (EBM), of course, is founded upon an epistemological power structure arranged hierarchally like a pyramid. The ‘quality of evidence’ determines whether or not something can be said to be true. On the lowest tier, the ‘base’ of this pyramid, is the Anecdote, considered worthless, encompassing many folk medical systems employing food and plant medicines and still used by the majority of the word as their primary care system, followed by: Cell Studies > Animal Studies > Human Studies > Clinical Trials > Meta-Analyses and Systematic Reviews of Clinical Trials.

Indeed, time and time again, I’ve pointed out how the hierarchy of evidence in EBM is defective in that it vastly undervalues basic science studies. The point is not that basic science is enough to establish the efficacy and safety of any given treatment. It’s not. Clinical trials still need to be done. However, basic science can be enough to close the door on the question of whether a treatment is efficacious and safe. The example of homeopathy comes to mind. Huge swaths of physics and chemistry would have to be not just wrong, but spectacularly wrong for homeopathy to work; basic science alone is enough to declare homeopathy so implausible as not to be worth testing in randomized clinical trials.

Ji also can’t resist attacking the straw man that anecdotes are considered “worthless.” They are not. However, they are the lowest form of evidence, and quite rightly so given how easily anecdotes can lead us astray. They are considered hypothesis-generating, rather than hypothesis-testing. Ji does, however, realize why EBM is so threatening to him, as he recognizes that the vast majority of evidence in support of his favored modalities are all anecdotes and that these are how most folk medical systems are supported.

That’s not the only straw man argument that Ji gleefully tries to set aflame with burning stupid:

This model assumes, in the characteristically Napoleonic style, that what it does not officially confirm as being true, is not true. Herbs and vitamins, for instance, are almost never considered to be “evidence-based” and credible because they have not run the gauntlet of prerequisite clinical trials required for them to be verified as therapeutic within this model. The fact that our bodies, for instance, require vitamin C in order to be alive, is not evidence enough to support the concept that it may be valuable to take it supplementally at doses beyond the recommended daily value (which may keep you only a few milligrams above starvation/deficiency values).

No, the model assumes that what has not been tested and confirmed to be true is unproven, not that it isn’t true. His “logic,” such as it is, is ridiculous, as well. It does not follow from the observation that vitamin C is required in the diet that using it as a supplement in megadoses (which, let’s be blunt, is what is meant by “taking it supplementally at doses beyond the recommended daily value”) is useful therapy. As I said before, observations an anecdote are not enough. They can be a starting point. They can be hypothesis-generating. They can also be profoundly misleading to the unwary, the ideologically blinded, and lovers of pseudoscience. Like Sayer Ji.

Of course, with this long, drawn-out lead up, you know we’re fast approaching the climax, and, if you’re familiar with cranks like Ji, you know what that climax probably is going to be. I can’t say I was too surprised when I came upon that climax:

Ultimately, Ioannadis’ findings reflect an inborn and potentially fatal error at the very heart of modern science itself: namely, a tendency towards scientism.

Scientism is the idea that natural science is the most authoritative worldview or aspect of human education, and that it is superior to all other interpretations of life. Furthermore, scientism accepts as real and valid only those things which it can confirm empirically; those things it does not or cannot confirm it is skeptical about, e.g. homeopathy, the existence of the soul, an innate intelligence in the body, or worse, outright denies as unscientific, or “quackery.”

That’s right. If you can’t prove your woo works through science, accuse your critics of “scientism”! Works every time. Well, not really. It’s one of the oldest, most transparent gambits in the book. It’s also hilarious in that it is clearly designed to cut science down a notch or two, to make it just one of any other “ways of knowing.” So how do cranks do that? They liken science to a religion! Yet they blather on and on about “soul,” “innate intelligence of the body,” and other spiritual, mystic, or outright religious concepts that they value. Oh, sure, Ji and his ilk gussy them up with the language of science, throwing around terms like “quantum,” non-locality, faster-than-light communication, to make his woo sound like science. In this, Ji is nothing more than a cut-rate Deepak Chopra.

A Deepak Chopra who sees fascists under his bed:

This is how we arrived at our present day pseudo-scientific medical dictatorship. I say pseudo- because insofar as science means an attempt to discern the truth without bias, it is a human faculty, a yearning of the soul, a constant challenge we must meet each and every moment we try to figure something out. Science is not a “brand,” a “possession,” an exclusive faculty of a caste of scientific elite, dispensed solely through monolithic institutions. It can not claim to deny anything and everything it does not explicitly confirm without being an organ and instrument of fascism, control, divisiveness and institutionalized and compulsory ignorance and myopathy.

Help, help, I’m being repressed by microfascists wearing microjackboots and microtruncheons! Big shock, Ji thinks it impossible for “natural medicine” ever to achieve legitimacy “within the present power structure.” Of course, the “power structure” has nothing to do with it. It couldn’t possibly be because these “natural cures” are rank quackery unsupported by science, evidence, or even convincing anecdotes, could it? Perish the thought.

In the end, Ji’s little screed is nothing more than a massive case of special pleading. Because his favorite woo can’t meet the standards of science, Ji wants different standards. Same as it ever was.