In the pages of Nature, a full-throated defense of “integrating” quackery into medicine

Oh, no, Nature. Not you. Not again.

It wasn’t enough that you were busted shilling for traditional Chinese medicine with a big, glossy advertising supplement a few years ago. I thought you had learned your lesson after that, as you didn’t do it again. Maybe I was wrong. Granted, your offense this time is not quite as bad as accepting cash from Saishunkan Pharmaceutical Co., ltd. and the Kitasato University Oriental Medicine Research Center to put together what was in essence pure propaganda for quackery, but, on the other hand, I do have to be worried that you might be thinking of backsliding, of moving that way again. What else am I supposed to think when I see a defense of quackery as credulously execrable as Jo Marchant’s op-ed entitled Consider all the evidence on alternative therapies, especially when it’s subtitled Investigate and incorporate the mechanisms of complementary medicine instead of rejecting it outright, says Jo Marchant?

It is rare that I see an article so full of fallacious reasoning, outright misunderstandings of science and placebo effects, and utter ridiculousness in a scientific journal. That the editor of Nature saw fit to publish this rubbish, thus sullying the pages of that respectable journal, is a travesty. That Jo Marchant, an otherwise respectable freelance journalist specializing in science and history, would make such appallingly bad arguments, was at first to me unexpected. Then I did some Googling and discovered that she’s written a book coming out in January entitled Cure: A Journey into the Science of Mind Over Body. If the blurb about the book is any indication, her article in Nature is a warm up for a whole lot of quackery:

Yet while we accept that stress or anxiety can damage our health, the idea of “healing thoughts” was long ago hijacked by New Age gurus and spiritual healers. Recently, however, serious scientists from a range of fields have been uncovering evidence that our thoughts, emotions, and beliefs can ease pain, heal wounds, fend off infection and heart disease, even slow the progression of AIDS and some cancers.

In Cure, award-winning science writer Jo Marchant travels the world to meet the physicians, patients, and researchers on the cutting edge of this new world of medicine. We learn how meditation protects against depression and dementia, how social connections increase life expectancy, and how patients who feel cared for recover from surgery faster. We meet Iraq war veterans who are using a virtual arctic world to treat their burns and children whose ADHD is kept under control with half the normal dose of medication. We watch as a transplant patient uses the smell of lavender to calm his hostile immune system and an Olympic runner shaves vital seconds off his time through mind-power alone.

Drawing on the very latest research, Marchant explores the vast potential of the mind’s ability to heal, acknowledges its limitations, and explains how we can make use of the findings in our own lives.

Calling Harriet Hall! I have a book for you to review early next year! Apparently Marchant believes that mind-body dualism is a thing and that you can think yourself healthy, at least to some extent. (After all, she does “acknowledge its limitations,” whatever those are. Perhaps she admits that you can’t cure cancer with your mind, although she does seem to think that meditation can actually slow aging, citing Elizabeth Blackburn’s work.) In any case, as you will see Marchant’s article is a sterling example of what you do when you advocate therapies that don’t have any specific therapeutic effects above and beyond that of placeboes. You embrace placeboes as real medicine, and claim your quackery exerts its therapeutic effect through placebo.

Yes, it’s amazing how a little Googling can let me know where a writer is coming from, for instance, as Marchant declares in her Nature article:

“Insane”, “a joke”, and “exactly the sort of thing the NHS should not be doing!” are a few of the Twitter responses to last week’s news that Britain’s Princess Alexandra Hospital NHS Trust wants to hire a reiki therapist for a hospital in Epping. On a salary of up to £22,236 (US$34,000) a year, the appointed person “will provide Reiki/Spiritual healing to patients to enable them to cope with the emotional, physical and spiritual issues of dealing with their cancer journey”.

Critics of the advert — and there are many — advocate instead what they call “evidence-based” approaches to health care. These critics should look again at the evidence — because it shows that to dismiss the benefits of alternative therapies is simplistic and misguided.

Um, no. Just no. It’s not “simplistic,” although that’s a frequent simplistic trope used by fans of quackery to dismiss criticisms of said quackery based on science. Oh, they will say. You silly English kniggits reductionistic Western scientist, you! I fart in your general direction! You do not understand the deep complexities and interrelatedness of our woo. Now, go away, or I shall taunt you a second time!

You silly English knight

I exaggerate, of course, but not by much.

Actually, British skeptics and advocates of science-based medicine have every right not to want their precious taxpayer funds, funds that could and should be used to pay for treatments shown to be effective based on science, rather than for rank quackery like reiki. It’s particularly irritating to me that this specific ad is looking for a reiki practitioner to ply his quackery on cancer patients, particularly breast cancer patients.

Now, I know the British seem to have a soft spot for homeopathy. After all, there was an NHS-funded homeopathy hospital known as the Royal London Homeopathic Hospital, until a few years ago when the people who run it realized that (1) homeopathy is too easy to attack because it’s so obviously not based in science and (2) they needed to diversify their quackery and get hip to the latest lingo, which is to “integrate” quackery with science-based medicine, the better to give it the appearance of scientific validity. That’s why a few years ago theRoyal London Homeopathic Hospital was reborn as the Royal London Hospital for Integrated Medicice. The other thing that Marchant seems utterly unconcerned about is that reiki is among the quackiest of quackeries. Indeed, whenever I would contemplate a ranking of quackery, I used to call homeopathy “The One Quackery to Rule Them All.” (It’s true, just search this blog for that phrase.) Lately, however, I’ve been wondering if that’s true. After all, reiki is basically faith healing that substitutes Eastern mystical claims that its practitioners can channel healing energy from “the universal source” through the practitioner into the patient. Substitute the word “God” for “universal source,” and you’ll see why I refer to reiki as faith healing.

So what’s quackier? Faith healing, or a treatment that claims that water “remembers” the healing substance that it’s been in contact with (conveniently forgetting all the nasty stuff it’s also been in contact with, like urine) and that diluting a substance makes it stronger. I don’t know, to be honest. It’s kind of like asking what stinks more, a sewer or a cesspit. I do know that, when you add all the other nonsense that goes along with reiki, like distance healing, and reiki does indeed given homeopathy a run for its money as far as quackery goes.

Of course, Marchant is quick to point out after this that she doesn’t believe in all that mystical mumbo-jumbo. Oh, no. She’s into science, ma-an. Rather, she believes in what I like to call the power of the magical placebo:

Let’s be clear, I don’t buy into the pseudoscientific claims of reiki and spiritual healers. There is no evidence that they can tap into and manipulate human ‘energy fields’ to clear blockages and heal the body. Like many alternative therapies, these practices perform no better than placebos in clinical trials.

Well, that’s a relief. I can hear the “but…” coming, and so it does:

But that does not mean that such treatments have no distinct therapeutic value. To dismiss people’s complex psychological and physiological reactions to serious illness — and how it is treated — as mere placebo effects is not helpful.

Neuroscience studies show that placebo effects can trigger significant physiological responses that are often identical to those created by drugs, ranging from the release of dopamine in the brains of people with Parkinson’s disease to a rush of endorphins for those in pain.

And there you have it. Marchant buys wholeheartedly placebo myth. Sure, she doesn’t go off the deep end, the way that Robert Schiffman did when he cited placebo effects as proof that God exists, but she does buy into the myth. Indeed, she sounds very much like a homeopath, whose similar nonsense I once took on. Anyone remember Heidi Stevenson? Actually, on second thought, maybe not. Heidi Stevenson stated flat out that placebo effects cannot cure, as part of arguing that alternative medicine is more than placebo, while Marchant argues, in essence, that placebo effects can cure. Well, not exactly, but close:

The standard ‘evidence-based’ argument is that this is irrelevant. Even if alternative therapies induce a biological response, sceptics argue, patients are still better off receiving trial-proven conventional treatments, because then they benefit from both a placebo effect and the active effect of the drug.

This logic misunderstands the nature of placebo effects. Not all placebos are the same, and alternative therapies can sometimes trigger larger responses than conventional ones do. For example, in one trial, fake acupuncture relieved pain more effectively than a fake pill (T. J. Kaptchuk et al. Br. Med. J. 332, 391–397; 2006); in another, it relieved symptoms of irritable bowel syndrome with fewer side effects than available drugs (T. J. Kaptchuk et al. Br. Med. J. 336, 999–1007; 2008). It is true that if a therapy cannot beat a fake version of itself in trials, it is not working as the therapist claims. But if it triggers a big enough placebo effect, it might still be the best treatment available.

Marchant is actually missing a part of the skeptic argument, which is that placebo effects do not affect “hard” outcomes. For instance, placebo effects have never been shown to increase survival in patients with cancer, (Yes, death is the “hardest” endpoint of all, as it’s rather indisputable whether a patient is dead or alive.) That is why placebo controls are rarely used in cancer clinical trials any more. Instead, we tend to compare experimental treatment versus standard-of-care or compare adding experimental treatments to the standard of care to the standard of care alone. In addition, placebo effects do not generally affect the physiology behind the disease process. A great example of this is a study of sham acupuncture versus albuterol inhaler in patients with asthma. The results showed that, yes, patients did feel better. They did feel less short of breath. However, the “hard outcome” as measured by spirometry showed absolutely no effect on lung function. So, basically patients felt better but weren’t actually better. In the case of asthma, this could lead to death, as a patient could have the false assurance that, because he doesn’t feel as short of breath, he must be doing better when he could be very close to full decompensation.

So what about the studies cited by Marchant? The first one was only a single-blinded study examining acupuncture and amitriptyline for arm pain versus their respective placebos from repetitive stress injury. The acupuncturists were not blinded to whether they were providing “real” or “sham” acupuncture. It also has an utterly unsurprising result: More invasive placebos, like sham acupuncture, have long to produce more placebo effect than less invasive placebos, like pills. This study in no way shows that “alternative therapies can “sometimes trigger larger responses than conventional ones do.” It just provides one more bit of evidence supporting the unremarkable conclusion that invasive interventions produce more placebo effects than non-invasive measures.

The second study was no better. It, too was single blind, with practitioners not blinded to assignment. It, too, does not show what Marchant thinks it showss. In fact, the study abstract looked very, very familiar. So I searched the archives, and guess what? I blogged about this very study when it came out in 2008, and you can read the details here. The CliffsNotes version is that what this study really showed is the importance of practitioner-patient interaction in enhancing placebo effects. I mean, seriously. Did Marchant even read the same study I did? I went back, read the study again, and read my blog post about it again. I didn’t recognize the conclusion.

So, having demonstrated that she has been thoroughly taken in by alt-med propaganda, Marchant happily goes all in advocating placebo medicine. Pointing out that people tend to look at alternative medicine for problems that don’t have a good treatment available in conventional medicine, she advocates this:

The benefits of therapies such as reiki and acupuncture go beyond what we normally think of as placebo effects, however. Alternative therapists do not get results just because they are particularly good at fooling people into thinking that they will get better. Many elements of the care they provide — from talking to touch — seem to have the power to relieve symptoms and even influence physical outcomes. These elements do not show up when therapies are compared against sham treatments, because they are present in both arms of a trial.

Such benefits can be indirect. For example, tackling patients’ anxiety during invasive procedures such as keyhole surgery can reduce the risk of dangerous fluctuations in heart rate. This results not only from the direct effects on physiology, but also probably from patients needing lower doses of sedatives and painkillers.

Conventional medicine, with its squeezed appointment times and overworked staff, often struggles to provide such human aspects of care. One answer is to hire alternative therapists.

No, no, no, no, a thousand times no! To expand on Ben Goldacre’s famous quip about how problems in the airline industry do not mean that flying carpets work, just because there are problems in medicine does not mean that we should hire quacks like reiki practitioners to fill in the gaps. If physicians and nurses do not have the time or training to provide the “human touch,” then the answer is to change the system so that they do have that time (hiring more science-based practitioners would be a start) and to train them so that they are better at it. The reason is simple, and it’s all the pseudoscientific baggage that comes along with alternative medical practice. It’s a problem that Marchant acknowledges as a “legitimate concern” only to dismiss that same concern thusly:

Critics say that this is dangerous quackery. Endorsing therapies that incorporate unscientific principles such as auras and energy fields encourages magical thinking, they argue, and undermines faith in conventional drugs and vaccines. That is a legitimate concern, but dismissing alternative approaches is not evidence-based either, and leaves patients in need.

Instead of rejecting such approaches wholesale, let’s learn from them. That means going beyond the simplistic practice of jettisoning anything that cannot beat placebo. We must tease out the real active ingredients of these therapies — things such as ritual, mental imagery, empathy, care and hope — so that we can learn how they work and find ways to incorporate them into patient care.

Marchant is actually attacking a rather massive straw man here. Yes, endorsing treatments incorporating unscientific principles does encourage magical thinking. That is true. However, the reason we oppose “integrating” such nonsensical therapies goes beyond just that. Such therapies are rejected because they don’t work. Yes, the criteria used to evaluate them is that horribly “simplistic” standard of doing better than placebo. It’s a single, science-based standard that we advocate, one the applies to potential medicines and treatments, wherever they come from, “conventional” drug development pathways or “alternative” medical traditions. There are only three kinds of medicine: Medicine that has been shown to work scientifically, medicine that hasn’t been shown to work scientifically, and medicine that has been shown not to work. Guess which two categories apply to the vast majority of alternative medicine, if not all of it? Yes, the latter two. Of course, alternative medicine that is shown scientifically to work ceases to be “alternative” and becomes just medicine. Unfortunately, the concept of “integrative medicine” is special pleading, a transparent attempt to bypass the step of scientific validation in going from “alternative” medicine to medicine.

Marchant appears to misunderstand the reasons why advocates of science-based medicine are alarmed by the “integration” of pseudoscience and mystical thinking into medicine in the form of “integrative” medicine. She seems to think it’s just because we don’t like them, While it’s true that we have a distaste for the utter nonsense behind alternative medicine like homeopathy and reiki, our objection goes beyond mere disgust at what we perceive (correctly) as quackery. There is also the issue of prior plausibility and Bayesian thinking, in which the posterior plausibility that a “positive” result of a clinical trial is really indicative of an effect depends on the prior plausibility. To put it very simply, the lower the prior plausibility, the more likely seemingly “positive” results are real effects are “false positive” results. That is the key difference between evidence-based medicine and science-based medicine: SBM incorporates prior plausibility based on basic science considerations into its assessment of treatments. EBM, in essence, does not, which is why quackery like acupuncture, homeopathy, and even reiki can be touted by some as “evidence-based.”

Finally, we already do “tease out the real active ingredients” of placebo effects. One of the papers cited is an effort to do just that. However, as virtually all proponents of “integrative medicine” do, whether they realize it or not, Marchant is advocating a classic false dichotomy: Embrace quackery or abandon patients. It’s a false dichotomy because we don’t have to abandon science and reason to avoid abandoning patients, and problems with the “human touch” in medicine can be don’t require embracing magic to solve.

It’s not as though we haven’t been making these same points again and again and again for as long as I can remember. The problem is that advocates of “integrating” quackery into medicine keep making the same fallacious arguments. Now Jo Marchant is doing the same thing. These same old pseudoscientific arguments regurgitated by her are no more compelling or impressive than they’ve ever been. It’s just sad that the editor of Nature didn’t see that or didn’t care. As a result, there is now a defense of spending precious NHS resources to offer quackery to cancer patients.

Contrary to her view, it is not unscientific to reject alternative medicine, nor do critics do so because of their lack of sophistication leading them to embrace “simplistic” ideas. We understand alternative medicine all too well, clearly better than Jo Marchant, who could really use to read this article on integrative oncology. We also understand that, as study after study fails to find effects of various alternative medicine treatments above placebo effects, the narrative about “integrative medicine” is morphing to embrace placebo medicine. It’s what you do when what you have doesn’t have any specific therapeutic effects. You treat placebo effects as though they are some sort of magic, Secret-like way of “healing yourself.”