The fallacy of moderation at BMC Complementary and Alternative Medicine

One of the fun things about blogging is that I can often follow how various issues develop and, more importantly, insert my opinion into the issue. As bizarre as it seems to me even almost nine years after starting this blog that anyone keeps reading what I have to lay down (and it still does seem bizarre that anyone cares much what I have to say every day, but several thousand of you apparently do), that’s what I continue to be here for. Last month, I wrote about an editorial by the director of the National Center for Complementary and Alternative Medicine (NCCAM) in which she called for a “nuanced conversation” about “complementary and alternative medicine” (CAM, or as it’s now called these days, “integrative medicine”). As you might imagine, I wasn’t impressed. Indeed, what I lay down here day in and day out is a nuanced conversation about CAM, at least as nuanced as it deserves on a scientific basis. Not long after that, there was an article in The American Journal of Medicine about the “future of integrative medicine.” Personally, I was unhappy that the “future is now” when it comes to integrating quackery into real medicine.

Barbarian that I apparently am when it comes to CAM and “integrative medicine,” I couldn’t help but be amused when you, my readers, sent me a link to a post on the BMC Series Blog by Tom Rowles entitled Striving to bring balance to the complementary medicine debate, which uses Brigg’s editorial and the article about the future of CAM as a jumping off point. It occurs to me: Whenever I see the word “balance” coupled with the word “debate” and the term CAM (or any related term), I know I’m in for a whole lot of the logical fallacy known as the fallacy of false balance, also known as the fallacy of the golden mean or the fallacy of moderation, and the author of this post, Tom Rowles, doesn’t disappoint. While not-so-subtly denigrating skeptics and supporters of science-based medicine who criticize the pseudoscience and quackery that are at the heart of so much so-called CAM or “integrative medicine.” When faced with a science-based medicine versus the pseudoscience and quackery of so much CAM, Rowles touts how the BMC takes a “balanced” approach, which basically means in most cases, splitting the difference, proclaiming in the very first paragraph:

Is a balanced outlook on complementary medicine research even possible? BMC Complementary and Alternative Medicine would like to think so, and would like your help to achieve this.

I’d be more than happy to help the BMC out, but I doubt they’d like my version of a “balanced” solution, because my balance would require completely eliminating balance. There is no need for it; either a treatment is science-based, or it is not. Yes, I know there are gray areas, but in most cases with CAM we aren’t talking about gray areas. For example, homeopathy is not a “gray area.” It is pseudoscience. Similarly, even areas of CAM that are presented as “science-based” are, more than anything else, a triumph of “rebranding” science-based modalities (diet, nutrition, and exercise, for example) as being somehow “alternative.” Either that, or CAM “woo-ifies” science-based modalities like nutrition by insisting that you need all sorts of supplements that you do not, in fact, actually need, or layers all sorts of mysticism onto exercise, as in yoga and Tai Chi.

Next up, Rowles then, seemingly intentionally, trivializes the criticism of CAM as being just another disagreement. Just like Marmite, you either love it or hate it:

Whatever your stance on Complementary and Alternative Medicine (CAM), whether you feel that it is an important part of healthcare that should be taken more seriously, or whether you denounce it as ‘quackery’, I think we can all agree that it is a subject that generates strong opinions. To use a comparison that I’m afraid will probably only work for our British readers, it is the Marmite of the medical and scientific world: You either love it or you hate it.

It kind of makes CAM and science-based medicine seem like different foods, styles, or other things that individual tastes determine whether a person likes them or not. Maybe this season CAM will be in style and next season SBM will be the taste du jour. Don’t like SBM? Hey, try CAM! Or vice-versa! So when Rowles notes that both of the above articles “negative reactions from the anti-CAM ‘blogosphere’ and much debate in comments sections,” I can’t help but wonder if in part they’re referring to me, given that it’s really only been at most a handful of bloggers who wrote about the article. Or maybe it’s just my massive ego. Who knows? Who really cares? (Well, actually, given my massive ego, I do.)

In any case, Rowles touts the utter superiority of BMC Complementary and Alternative Medicine (BMC CAM) based on what he proclaims as its scrupulous effort to “remain neutral.” But, what, exactly, does that mean? What is “neutral” with respect to SBM versus CAM? Rowles is no help:

We fervently believe that research into alternative therapies is important and necessary, with regards to both positive and negative results (see this previous blog for more on our position on negative studies). We feel that it is only with this balance that any truly beneficial CAM therapies will make their way into common practice. However, to do this requires a circus-worthy tightrope walk between open-mindedness and scepticism which can sometimes be difficult to maintain.

This is typical nonsensical CAM-speak. Rowles claims that BMC CAM is neutral in such a way that requires walking a tightrope between open-mindedness and skepticism, but admits that it “fervently believes”—not just “believes,” but “fervently believes”—that research into alternative therapies is “important and necessary.” Moreover, they justify this fervent belief by appealing to such research as the only way that “truly beneficial CAM therapies” will enter into common medical practice. Here’s my fundamental disagreement, and it’s a simple one. I reject the entire category of CAM as a false category and the division between SBM and CAM as a false dichotomy. To me, any medicine or treatment, regardless of where it comes from, should have a valid scientific rationale rooted in good basic science, and it must have valid evidence from well-designed clinical trials to support its efficacy and safety. If an “alternative therapy” can achieve that, then I have no problem adopting it as “medicine.” As the oft-repeated cliche goes, attributed to skeptics as diverse as Richard Dawkins and Tim Minchin, by definition, alternative medicine is either proven not to work or unproven. Medicine that is proven to work scientifically ceases to be “alternative” and becomes just “medicine.”

Rowles does do an interesting thing, though, for a CAM apologist (and, make no mistake, he comes across as a CAM apologist in this blog). Sure, he appeals to science, as most CAM apologists do, and claims to be extra super rigorously scientific (or, in this case, that BMC CAM is extra super rigorously scientific) in addition to being totally neutral, but he also echoes the arguments of supporters of SBM like me and insists that BMC CAM is not only extra super rigorously scientific but that it also insists on a plausible scientific mechanism by which a CAM treatment can work before publishing studies on it in the journal. Unfortunately, he misses something. Can you tell what it is? Here’s the paragraph:

We do this by always keeping in mind that we are, before everything else, a scientific journal. This is why we are generally unwilling to consider any manuscript on therapies that do not have a clear underlying scientific rationale. It is also the reason that you will very rarely see any studies dealing with energy therapies or homeopathy within the pages of BMC Complementary and Alternative Medicine.

That’s right, maaaan! It’s science! Well, except for those pesky energy therapies and homeopathy, which we never only rarely publish. When it comes to pseudoscience and quackery, it is apparently possible to be a little bit quacky, just like it’s possible to be a little bit pregnant. Wait, strike that.

Out of curiosity, I searched the journal for “homeopathy” and found quite a few articles. Most were more general articles about CAM that must have mentioned homeopathy, but there were several studies of homeopathy, including a protocol for the homeopathic treatment of irritable bowel syndrome, a model for homeopathic effects based on nanoparticles (one of the favorite explanations that aren’t for this particular quackery these days), homeopathy for mental fatigue, and even in vitro studies of homeopathy. It’s even a study that I blogged about! There’s also the odd study on various energy therapies here and there.

Unfortunately, its claims for scientific rigor not withstanding, BMC CAM seems willing to publish about most forms of CAM, although admittedly my perusal of the tables of contents of the journal revealed a preponderance of articles on herbs and natural products. Regular readers can probably predict what I’ll say about that: Studying natural products is not “alternative” or “complementary.” It is the very old, very science-based subdiscipline of pharmacology known as pharmacognosy, a.k.a. natural products pharmacology. It does not need its own “alternative” journal; there are plenty of pharmacology journals that publish lots of pharmacognosy studies. Segregating studies like this in CAM journal and mixing them in with studies of homeopathy does nothing for the credibility of herbalism or herbal remedies.

I’ll finish by reiterating a one of the key themes of this blog since its inception in 2004, and that’s SBM doesn’t distinguish between “alternative” and “conventional.” There should be one science-based standard applied equally to all medicine. The problem, of course, is that the vast majority of CAM fails that standard from the standpoint of scientific plausibility, basic science, and clinical trials. Rare it is that a CAM therapy can meet that standard—incredibly rare. Indeed, the vast majority of CAM is no better than an elaborate placebo justified by misguided claims of “neutrality” and and rigorous therapy that is no more than what Harriet Hall refers to as “tooth fairy science.”