The fixed mindset of medical pseudoscience

One of the key principles of skepticism, particularly in medicine, is that correlation does not necessarily equal causation. I emphasize the word “necessarily” because sometimes skeptics go a bit too far and say that correlation does not equal causation. I myself used to phrase it that way for a long time. However, sometimes correlation does equal causation. However, much, if not most, of the time it does not. So how do we tell the difference between when correlation might well equal causation and when it does not? Science, of course, and critical thinking. Science is the main reason that we know that all those stories of autistic regression after vaccination are virtually certainly coincidence. Whenever you have millions of children receiving vaccinations around the same age that the first symptoms of autism manifest themselves, by random chance alone there will be a lot of children whose symptoms first manifest themselves within a few days of receiving a round of vaccinations.

Of course, one of the major characteristics of the antivaccine movement (of course) and many other advocates of pseudoscience is to confuse correlation with causation. It’s not because they’re stupid. It’s because that’s the way our brains are wired, to attribute causation to a thing that happens right before another thing. Add fear of big pharma and the normal human revulsion at seeing needles stuck into the most precious thing in the world to them (their babies), and it’s not hard to see how some parents would blame vaccines for their children’s autism if their child happens to be one of those children who exhibit autistic symptoms by coincidence not long after a round of vaccinations. This attribution of causation to a correlation is remarkably resistant to science and reason, as the continued existence of the antivaccine movement and the resistance of individual antivaccine activists demonstrate.

So when I came across a post on that wretched hive of scum and quackery (other than Age of Autism), The Drinking Thinking Moms’ Revolution entitled Reporting Adverse Reactions: VAERS and FAERS, I saw it immediately as a “teachable moment” that demonstrates the general principle of how people prone to accept pseudoscience (like antivaccine misinformation and “autism biomed”) see the world. The post is by one of the Drinking Thinking Moms whom I don’t recall having encountered before, someone who goes by the ‘nym Rogue Zebra. A perusal of her archives shows not very many contributions to the blog dating back only six months. A quick search reveals that she must have been a guest blogger who was made a regular.

Whoever she is, she cheerfully describes to us the world view of an antivaccinationist as she describes how she filed a FAERS report. To be honest, I didn’t know (or had forgotten) that FAERS exists. Those of us who follow the antivaccine movement know what the VAERS system is, namely the Vaccine Adverse Event Reporting System. Its function is basically as its name indicates: It’s a system to report suspected adverse reactions to vaccines. Of course, the main problem with VAERS (and one of the reasons antivaccinationists love it so much) is that anyone can report any adverse event, whether there’s a reason to suspect that it’s due to a vaccine or not—and antivaccinationists have done just that. Indeed, it’s pretty clear that litigation has distorted the VAERS database as lawyers trying to claim damages for “vaccine-induced autism” have urged parents to report cases of autism to VAERS. Indeed, it’s not for nothing that I’ve referred to antivaccine activists mining the VAERS database as “dumpster diving.” That’s not to say that the VAERS database is useless. It still serves as a useful “canary in the coalmine” to alert the CDC of possible new adverse reactions to vaccines. It’s just basically useless for any sort of prevalence or incidence study. After all, if you can submit an adverse reaction in which you claim a vaccine turned you into the Incredible Hulk, there’s an issue.

Well, it turns out that there’s a similar database for reporting adverse reactions to drugs, biologicals, supplements, and medical devices, basically anything other than vaccines, called FAERS (FDA Adverse Event Reporting System). This is the story of how Rogue Zebra entered a FAERS report. Here’s what provoked it:

So what happened to make me file a FAERS report? We had a follow-up appointment with our pulmonologist where I filled out paperwork citing recent health changes. We were escorted to a room by a nurse who wheeled in a cart for a pulmonary function test (PFT). Crash has difficulty clearing mucous and secretions due to muscle weakness, necessitating daily maintenance nebulized medication and HFCWO (high-frequency chest wall oscillation) treatment. Crash did her first two PFTs to get an average without issue. Normally, she would be given a rescue medication in inhaler form before doing a third PFT to open airways to their maximum capacity. This time the nurse wanted her to use a “spacer” (chamber that holds aerosolized medicine) with the medication. She doesn’t use one at home, so when given a choice she chose the nebulized medicine instead. She has used the rescue medication in nebulizer form before, but hasn’t needed it at home in over a year. Her PFTs were all in the normal range of 70%+, and sleep is great with a new BiPAP (bilevel positive airway pressure) mask after our last visit, so no changes to home protocol or her nighttime BiPAP. Easy appointment with no changes is good news!

So far, so good. Nothing out of the ordinary here. Then:

My daughter waking me at 5 a.m. the next morning was not so good. I was late going to bed, working on a more in-depth blog that requires scientific research. After four hours of sleep, I drowsily heard her making noise — I was awake! Crash and I went downstairs, settling in while I tried to elicit what caused the early rise. Not two minutes later, we were in the bathroom talking 3 Ps (poop, puberty, pain/UTI) with her looking white as a ghost. The path from bathroom to living room would be traversed seven more times in the next two hours. Finally, evidence of the adverse reaction presented (specifics reserved to preserve her dignity). She has never experienced this symptom before in 11 years, so deciphering clues was challenging. We recalled that, usually, at the pulmonologist’s she has the inhaler version of medication rather than the nebulized version for PFTs. I am 100% confident that the nebulized medication was the cause as it was the only new thing introduced. The cascade of consequences for the next 24 hours included cycles of nausea, lack of appetite, fatigue, false bursts of energy after five bites of carbohydrates, roller-coaster of sugar highs and lows, and arguments about the protein-to-carbohydrate ratio in her food. Five days later, she is stable without having needed IV fluids to restore what was lost. *Shout out to IonCleanse by AMD footbath for nausea elimination.

Of course, IonCleanse is just another brand of “detox footbaths,” a modality that is about as pure a form of quackery as I can imagine, so much so that I featured it as one of my Friday Doses of Woo eight years ago.

So how likely is it that this was an adverse event related to the nebulizer medication? Consider first that, most likely, the drug involved was albuterol. We don’t know for sure, because she never identifies the drug by name, but I’m playing percentages here based on how commonly albuterol is used for the purpose described in this anecdote. Known adverse events due to albuterol inhalation don’t really include explosive diarrhea or much of the rest of the symptoms described above. Note what Rogue Zebra fixated on: The fact that her daughter used the nebulized version of the drug rather than the inhaled version of the drug, which she had used many times before, is incredibly unlikely to have anything to do with her daughter’s illness. After all, an inhaler provides a single metered dose that needs to be inhaled right away, while the nebulizer is a more gentle way of administering an inhaled medication that provides it in the form of a fine mist. Also, inhalers usually contain more than just the drug, such as the propellant and surfactant, while the nebulizer version is just an aqueous solution of albuterol, usually 0.5%. Of course, if the drug was not albuterol, the same considerations still likely apply.

Not surprisingly, the doctor didn’t think her daughter’s problems were due to the nebulized drug, because, of course, it’s incredibly unlikely that it was. There was also no notice of these sorts of symptoms as an adverse event to the drug on the manufacturer’s website. A nurse, quite reasonably, suggested that it might be a GI viral illness, which is really the most likely culprit for symptoms like this in a child (or even an adult, for that matter). So is it possible that this reaction was due to the nebulized drug? Yes, of course. It’s just incredibly unlikely, particularly given that her daughter’s reaction was 15 hours after the dose.

Rogue Zebra would have none of it:

So I filed a FAERS report. This episode is not normal for this child. I cannot accept the dismissal by our care team that “correlation does not equal causation.” Neither should you. File your VAERS and FAERS reports.

There you have it, in a nutshell. This is the thinking that is responsible for the antivaccine movement, an utter refusal to accept the possibility that the post hoc ergo propter hoc is a logical fallacy.

As I’ve said before, this is a fallacious way of thinking to which we are all prone. Refusal to admit that our personal observations are generally not a very good way to impute medical causation is also a form of arrogance, for which the humility of skepticism, which tells us that our ability to determine causation based on our own personal experiences is nowhere near as good as we think it is, is the cure. Most human beings have a hard time accepting this, particularly with respect to people and things they care deeply about.