One of the arguments used by skeptics regarding alternative medicine that is most understood (at times, it seems, willfully so) is the role of prior plausibility in assessing alternative medicine treatments. Indeed, even some physicians seem unable to comprehend the idea that there are some treatments that are so implausible on the basis of known, well characterized basic science alone—cough, cough, homeopathy, cough, cough energy medicine!—that they can be safely and, yes, scientifically dismissed as impossible just based on what we know about physics, chemistry, and biology, no randomized, double-blind, placebo controlled clinical trials even required. (I know, I know. What is a placebo in clinical trials of homeopathy, given that homeopathy is basically water?) Not surprisingly, when clinical trials of such magical modalities are actually carried out, their likelihood of being negative is very much correlated with how well designed the randomized clinical trial (RCT) is designed and carried out. Unfortunately the methodolatry of evidence-based medicine (EBM) frequently leads this basic concept to rub physicians the wrong way?
What do I mean by methodolatry? It’s a term I first learned way, way back during the H1N1 pandemic in 2009, when Revere taught it to me. Basically, it is defined in medicine (loosely) as the “profane worship of the randomized clinical trial as the only valid method of investigation.” (More generally, the word “methodolatry” refers to focus on a method rather than the totality of the scientific question being answered.) It is the central flaw of evidence-based medicine, at least when it comes to investigating highly improbable alternative medicine treatments (like homeopathy and energy medicine). Indeed, methodolatry is a flaw in EBM that leads normally rational physicians to conclude that, if there isn’t a negative RCT (or, preferably, multiple negative RCTs that can be combined into a meta-analysis), then we can’t ever truly conclude that a treatment doesn’t work, never mind how ridiculous the treatment is from a strictly basic science standpoint. Indeed, this central blind spot of EBM is the reason why the concept of science-based medicine (SBM) was introduced. The idea, at least with respect to highly implausible treatments, was (and is) to consider prior plausibility when evaluating the evidence regarding alternative medicine.
I was reminded of how bad physicians can be at wrapping their head around this very basic concept by an article by someone named Dr. Jason Fung. He’s a nephrologist (I can’t help but think of another nephrologist with whom I’m acquainted), and he’s unhappy with skeptics, so much so that he wrote a screed entitled Debunking the Debunkers. Rather oddly, he chooses a very strange hill to die on, as you will see. But first, we have the mandatory unflattering comparison of skepticism to religion:
The Medieval Crusades were a series of holy wars sanctioned by the Latin Church. It seems incongruous today, but the Catholic religion was used as justification to bring war, death and destruction to thousands of innocent people. The last time I checked, the Bible did not exactly espouse the use of brute force to subjugate other peoples. I don’t recall any passage in there that says “We will save the heathens even if we need to kill them to do it.”
I’m reminded of this same incongruity every time I read about some person in the media trying to ‘debunk’ some procedure or other. The most recent article in the Toronto Star celebrates how people like Tim Caulfield help the public by debunking celebrity culture. They perceive themselves to be ‘myth busters’, but in reality, they are selling the same pseudo-science they pretend they are ‘debunking’.
Of course, I can’t help but note that it isn’t just Tim Caulfield featured in the article that appears to have sparked Dr. Fung’s ire. Yes, I’m in it too. So’s Yvette d’Entremont (a.k.a. SciBabe). All of us explain in the article that, for one thing, skepticism is about a lot more than just “debunking.” Apparently Dr. Fung didn’t read that part. I’m rather amused, though, how Dr. Fung seems to think that we are akin to the Catholic Church during the Crusades, sweeping in and trying to subjugate…who?…by force, complaining, ironically enough that most of the “people online pretending to be ‘myth busters’ are just people who scream for attention and don’t perform any real science” and that they are “simply trying to yell louder than the person they are trying to debunk.”
Now here’s the very, very odd hill on which Dr. Fung chooses to die, scientifically speaking, in the process providing one of the best demonstrations of the concept of “methodolatry” since the H1N1 pandemic that I’ve come across in a long time:
Let’s take the well publicized example of the jade egg sold by Goop, a wellness site promoted by celebrity Gwyenth Paltrow. It sells a jade egg that may be inserted into the vagina for increased sexual energy for $66. There has been considerable controversy about this pseudoscience and many have taken up the role of ‘mythbuster’. So let’s see what real science looks like.
First, is there any evidence that the jade egg works? No. This is an unsubstantiated claim – a claim made without any evidence to back it up. Second, and this is just as important, is there any evidence that the jade egg does NOT work? No. This, too is an unsubstantiated claim. This is not pseudo-science. There is no science at all. Science says that there is no evidence for and none against, so it’s simply unknown. But the ‘debunkers’ claim that the jade egg does NOT work and further may be dangerous. Therefore, these debunkers are engaging in the same unsubstantiated claim slinging as Goop. It is this complete hypocrisy that annoys me. Let me be clear. Do I think the jade egg works? No. But I don’t actually know, so I do not claim it either works or does not work.
I laughed out loud when I read the passage above for the first time. When I stopped laughing, however, I realized that Dr. Fung had provided me with a lovely gift, a “teachable moment” about methodolatry and the differences between EBM and SBM. What Dr. Fung is describing is an EBM paradigm. Prior probability doesn’t matter the least to him if there is no clinical trial evidence to support it. Don’t believe me? Dr. Fung makes my case for me by immediately saying almost exactly that:
What is needed to actually, scientifically debunk this claim? You need to gather a group of, say 100 women, and have half use a jade egg, and the other half use, say, a stone egg of the same weight. You would not let the women or the researcher know which egg they are using and then measure their sexual energy at some later date. If there is no difference, then, and only then, can you claim to have successfully debunked the jade egg.
I can’t help but wonder what sort of tests or instrument Dr. Fung recommends for measuring a woman’s “sexual energy.” The wag in me also can’t help but point out that, if Dr. Fung is really serious about this, he left out a control group, namely a no-egg control. Granted, there could be no blinding of this group, but no-treatment controls are not infrequently used in acupuncture studies; they provide a good baseline against which to estimate placebo effects from the sham treatment. Such a group isn’t necessarily mandatory, though; so I’ll let it slide, albeit not without a little snark and mockery. That’s because, when Dr. Fung gets to the bottom of a hole, he keeps digging:
So, is the jade egg harmful? The debunkers claim that it is potentially harmful and could harbor bacteria. Has there ever been a case in the last 200 years of the worldwide medical literature describing a case report of severe infection from a jade egg? No. Zero. There’s been lots of case reports of this happening for tampons, for example, but not for jade eggs. So, debunkers ignore the need for scientific evidence and instead engage in fear mongering using unsubstantiated claims once again, all the while, believing themselves to be champions of science. That’s hypocrisy.
The origin of the claim that’s so chapped Dr. Fung’s posterior, as far as I can remember, was actually not Tim Caulfield, but rather Dr. Jen Gunter, a real OB/GYN. Here’s what she said about it:
As for the recommendation that women sleep with a jade egg in their vaginas I would like to point out that jade is porous which could allow bacteria to get inside and so the egg could act like a fomite. This is not good, in case you were wondering. It could be a risk factor for bacterial vaginosis or even the potentially deadly toxic shock syndrome.
Notice anything? Her statement is considerably less…definite…than Dr. Fung represented it. Dr. Gunter did no more than make a reasonable extrapolation from what we know about vaginal physiology, pointing out that putting something porous into the vagina and leaving it there is a risk factor for infection, which can range from vaginosis to possibly even toxic shock syndrome. Her basic point was that there is possibly a risk for doing something that has no known benefit. In other words, the claims made by Gwyneth Paltrow’s Goop in order to sell jade eggs are unfounded and, based on what we know about anatomy, physiology, and biology, almost certainly untrue.
Of course, whether or not jade eggs increase a woman’s “sexual energy” or are a risk factor for toxic shock syndrome is not what Dr. Fung is about. The hilarious thing is that, as he beats a straw man of what skeptics say about woo like jade eggs using the methodolatry that too many proponents of EBM engage in, it turns out that he’s not really that much about EBM at all. Not really. What he’s really about is something very different, which he doesn’t take too long to reveal:
Since there is no evidence either for or against the jade egg, then this question now falls to the clinician, the person who treats people. Here, the main question is not ‘Does this really work’ but instead it is ‘How’s that working for you?’. Remember that there is a powerful placebo effect. If I rub moisturizer on my son’s stomach for his tummy ache (which I do all the time), it will work in 30-50% of cases. The same is probably true for the jade egg. So, what is the risk: benefit ratio? The best thing that will happen is that it works as advertised (30-50% of cases). The worst thing is that you will waste $66 dollars. That’s actually not a bad tradeoff.
Notice that Dr. Fung doesn’t have the least bit of concern over what skeptics are really about here: Consumer protection. Remember, he openly admits that there is no evidence for the claims made for these polished stones. True, he tries to spin that into implying that we know nothing at all about the claims made for jade eggs because there are no RCTs, the height of methodolatry. But then he goes on to say it’s all about the “individual” and “placebo effect.” Moreover, he doesn’t mind that Goop is charging $66 for essentially nothing of value, at least as far as women’s health goes.
He also starts with a rather predictable rant against skeptics and conventional medicine. Basically, he’s trying to paint us as hypocrites:
Compare this to the use of angioplasty for stable heart disease. These stents to open up heart arteries have been used for many decades to prevent heart attacks in patients with closed arteries. It’s an invasive procedure that has real risk of bleeding, infection and perforation/ death. It also was insanely expensive for both the equipment and doctors fees. Recently, several studies have conclusively shown that these procedures for stable patients is completely useless with the first studies being done in the 2007. So, here is a procedure that has scientifically been debunked. We’ve wasted billions of dollars and caused untold side effects over the last 10 years that doctors have continued to perform this largely useless procedure. Where were the debunkers? Wouldn’t this be better to debunk instead of largely harmless jade eggs?
Challenge accepted, Dr. Fung. Challenge accepted. I also point out that skeptics are quite able to walk and chew gum at the same time.
However, Dr. Fung really gives the game away here:
The other thing that fascinates me is why so many people routinely use alternative medicine. Most of homeopathy, naturopathy etc. has little evidence to back up its claims. This does not mean it doesn’t work, it simply means that we do not know if it works or not. But clearly, the general public feels that this is equal to the ‘science’ of conventional medicine, of which I was trained for many years. Why?
With respect to homeopathy, I respond: No! No, we do know whether homeopathy works or not. It doesn’t. For homeopathy to work, huge swaths of well-established science regarding physics, chemistry, and biology would have to be not just wrong, but spectacularly wrong. Yet, in his methodolatry, Dr. Fung can’t come out and say that homeopathy doesn’t work because it can’t work. Clinical trials of homeopathy are, in effect, clinical trials of magic. Indeed, homeopathy is magic based on sympathetic magic whose adherents actually believe that you can treat conditions with saliva from a rabid dog diluted away to nothing. This is the sort of thing about which Dr. Fung claims that we “don’t know whether it works or not.”
Of course, perusing Dr. Fung’s blog, I get the feeling he’s not very good at this science thing. One example that stood out was an article What Medical Research Gets Wrong About Cancer. Let’s just put it this way. Dr. Fung is quite impressed by Paul Davies, the physicist who’s clueless about cancer but sees fit to lecture cancer biologists about what he thinks they’re getting wrong about cancer.
It looks like I have another doctor behaving badly with respect to science to keep an eye on. I do thank him, however, for this “teachable moment” regarding the difference between EBM and SBM and why “we don’t know” is a cop-out when it comes to the claims for phenomena like jade eggs and homeopathy.