Every so often, I come across a quack unfamiliar to me, one whom I’ve never heard of before. So it was yesterday when my email inbox was contaminated with a missive promoting an article by Dr. Richard Amerling. Why did I get such a missive? Simple. I’m on a lot of email lists, which I monitor as one strategy to keep my finger on the pulse of quackery, pseudoscience, the antivaccine movement, and conspiracy theories. One such mailing list that I monitor is that of the American Association of Physicians and Surgeons (AAPS), of which Dr. Amerling is apparently a member, and it sent me a reference to an article by him, which he also had Tweeted out:
Why would it matter that Dr. Amerling is a member—a past president, even—of AAPS? Simple. AAPS is, in essence, the John Birch Society for physicians disguised as a legitimate medical professional society, which is how it’s managed to fool the press into taking its statements seriously and also why it’s been featured on this blog intermittently going back to when I first discovered it over 16 years ago. Politically, the AAPS is far right libertarian. In 2006, it was opposed to any form of government regulation of health care; considered the FDA and Health Care Financing Administration to be unconstitutional; was utterly opposed to Medicare; urged physicians not to participate in Medicare; described public health programs as “tyranny” (a point I’ll get back to later in this post); and liked to liberally quote Ayn Rand. Before 2006, AAPS had consistently viewed mandatory vaccination as a “tool of the state” and a threat to physician autonomy, while minimizing the contribution of mass vaccination to the elimination of various infectious diseases.
AAPS has been around a long time, having been founded in 1943 to combat “socialized medicine”; so by the time I discovered it the organization had already had six decades to go further and further into conspiracy theories. I also like to mention this history to counter the idea that the right wing embrace of anti-public health and antivaccine conspiracy theories is something new. It’s not just vaccines, either. AAPS has promoted medical quackery in addition to its antivaccine pseudoscience, including a view that is extreme even among antivaccine activists, namely that the “shaken baby syndrome” is a “misdiagnosis” for vaccine injury; its HIV/AIDS denialism; its blaming immigrants for crime and disease; its promotion of the pseudoscience claiming that abortion causes breast cancer using some of the most execrable “science” ever; its rejection of evidence-based guidelines as an unacceptable affront on the godlike autonomy of physicians; or the way the AAPS rejects even the concept of a scientific consensus about anything. Shortly before the pandemic, AAPS even published an article by Andrew Wakefield about how the MMR vaccine could lead to a mass extinction of humanity that later served as the template for Geert Vanden Bossche’s conspiracy theory that COVID-19 vaccines would lead to COVID-19 variants that could endanger humanity. Let’s just put it this way. The AAPS has featured publications by antivaccine mercury militia “scientists” Mark and David Geier. Unsurprisingly, it didn’t take AAPS long to pivot to conspiracy theories involving COVID-19 and COVID-19 vaccines.
Back to Dr. Amerling, though. The article is about more than just COVID-19, because of course it is. He starts by attacking evidence-based medicine (EBM) in general:
The medical profession’s adoption of sacrosanct “evidence-based medicine” set the stage for the widespread medical tyranny we are currently witnessing.
EBM sounds scientific, objective, and noble, but it was hijacked by industry to create clinical practice guidelines that came to dominate medical education and practice. These were only loosely based on evidence, mostly from industry-funded studies, or were created by “expert” doctors, the majority of whom were industry-funded. The embrace of the EBM narrative created the illusion of knowledge and the impression that there was only one “best practice” for any given situation. Of course, nothing could be further from the truth. Medicine and science are (or should be) continuously evolving and changing, with hypotheses being challenged and rejected or supported. EBM, however, in the hands of bureaucracies such as the National Institutes of Health (NIH), the UK’s National Institute for Health and Care Excellence (NICE), the World Health Organization (WHO), and the Centers for Disease Control and Prevention (CDC), became an instrument of medical tyranny.
AAPS has always been against EBM, misrepresenting EBM-based treatment guidelines as medical totalitarianism that somehow subverts the “will” of individual physicians treating individual patients. When docs like Dr. Amerling complain about EBM this way, they always seem to forget that EBM-based guidelines always have huge loopholes for physicians to use to deviate from them if they deem it appropriate. They also assume that there’s no such thing as a wrong answer in medicine, which is why any guideline that suggests a correct course of action based on existing science and clinical evidence is viewed with extreme suspicion. We see that same attitude among “brave maverick doctors” who have been promoting ivermectin and hydroxychloroquine as treatments for COVID-19, even as evidence has accumulated demonstrating that neither work. Interestingly, one of the claims that Dr. Amerling echoes is more of a left-wing anticorporate claim (namely, that EBM has been “hijacked” by corporations) that can be a not entirely unreasonable critique of EBM; however, when it’s used in this sort of context you know that it’s more an excuse to portray EBM as utterly corrupt and useless, rather than as a good-faith critique of how EBM guidelines are developed and iteratively modified.
It’s not enough, though, for Dr. Amerling to decry EBM as somehow fascistic. He has to go full Godwin and invoke the Nazis to demonize what he hates:
The medical profession, because we care for individual patients, is an essential bulwark against totalitarianism. Remember that Hitler first co-opted and controlled the doctors before implementing the Final Solution. Doctors who owe allegiance to the state will have difficulty standing up against policies that abuse the individual, or human dignity and life.”
The Hippocratic ethic of the medical profession stands in the way of the antihumanist, pseudoscientific Left. This ethic upholds the rights of our individual patients, including the elderly, the sick, and the unborn, and the noble goals of our profession to preserve life, to heal, and to soothe.
How have physicians gone wrong? As described by Ashley Fernandes in “Why Did So Many Doctors Become Nazis?” in the period leading up to and including World War 2, German physicians joined the Nazi party at a much higher rate than all other professions. German doctors were also organizationally and financially tied to the state.
It is actually true that German physicians joined the Nazi Party in higher numbers than other professions did. (If you want to learn a lot more about this particular topic, I highly recommend Robert Jay Lifton’s classic treatise The Nazi Doctors: Medical Killing and the Psychology of Genocide.) However, German physicians’ susceptibility to Nazi propaganda doesn’t exactly support Dr. Amerling’s argument that physicians are somehow always a “bulwark” against totalitarianism” very well; rather, it argues against it. Think about it. Why did Adolf Hitler and his Nazi Party appeal so much to physicians? Hitler told physicians that he would make them not just physicians treating individual patients, but physicians treating the entire volk, the German/Aryan people. Unfortunately, physicians responded to Hitler’s message quite enthusiastically. Contrary to Dr. Amerling’s characterization of physicians as essential warriors for freedom, German physicians before the rise of Hitler, it would seem, were actually all too receptive to totalitarian messages. Were this not so, the Nazi vision of eugenics would never have resulted in the horrific medical experiments carried out by Nazi physicians—or even, arguably, the Holocaust in general. Physicians were intimately involved in the Holocaust from the very beginning, particularly with the T4 Aktion euthanasia program.
Dr. Amerling isn’t offering an honest critique based on a fair reading of history, though. He just wants to Godwin public health officials and vaccine advocates, to portray them as being like the Nazis in their lust to control. To do that, he mixes a few legitimate criticisms of the pandemic response with a whole lot of bullshit. For example, he points out the cruelty of “absurd and inhumane rules restricting family visitation of sick and dying patients.” There is actually a critique there, but he mixes it with attacks on “strict treatment protocols that were at best ineffective, and at worst lethal” and incentivization of “diagnosing COVID-19 and following the ‘guidelines,'” the latter claim being a conspiracy theory that doctors were somehow “incentivized” to misattribute deaths as being due to COVID-19, a conspiracy theory that arguably originated with John Ioannidis.
Most American doctors followed CDC and Food and Drug Administration (FDA) “guidance.” They withheld early life-saving treatments. They abandoned patients, instructing them to stay home until they literally couldn’t breathe. They did not object to the blatant, harsh censorship and harassment of colleagues who were utilizing repurposed drugs to fight the disease. They failed to recommend general health measures aimed at improving metabolic and immune health.
It grieves my soul to make this analogy with what has happened to American medicine. But what have we seen over the past two plus years of the COVID-19 pandemic?
Doctors did not object to the imposition of mask mandates, despite clear evidence of their lack of benefit and obvious harms, especially to young children. Nor did they protest lockdowns, whose inefficacy and massive collateral damage were immediately evident.
“Did not object”? Dr. Amerling is a doctor; he’s objecting. AAPS is made up of mostly all doctors; as an organization it’s objected all along. “America’s Frontline Doctors” are (for the most part) all doctors. The signatories of the Great Barrington Declaration included a lot of physicians. Dr. Scott Atlas and a lot of the ivermectin-pushers are all doctors. They all objected to mask mandates, “lockdowns,” and efforts to rein in ivermectin and hydroxychloroquine quackery. The unfortunate fact is that a significant minority of physicians did object to evidence-based public health interventions, including even vaccines. Worse, they lent misinformation and disinformation the appearance of scientific legitimacy based on their trusted professional status.
Finally, Dr. Amerling goes full antivax, complete with a litany of typical anti-COVID-19 vaccine nonsense:
For the most part, doctors enthusiastically backed the mass “vaccination” of all humans, regardless of any clinical considerations such as prior immunity, low risk of severe disease, pregnancy, and many other clear contraindications. They even denied life-saving organ transplantation when either donor or recipient was unvaccinated, a policy with zero scientific merit.
What about human experimentation? These gene-based “vaccines” are all experimental. How many participants have given truly informed consent? How many were told the absolute risk reduction for serious infection is less than 1%?
For the most part, doctors did back COVID-19 vaccination because COVID-19 vaccines have been safe and effective and have been estimated to have prevented over 2 million deaths and 17 million hospitalizations. Even so, there still remain a disturbing number of antivax doctors—doctors like Dr. Amerling, who still peddles the lies that COVID-19 vaccines are still “experimental” (dude, the Pfizer and Moderna vaccines are FDA-approved for adults now); minimizes their benefit, while elsewhere falsely claiming in the article that the vaccines kill; and touts “natural immunity” as being better than vaccines, even though COVID-19 has shown a remarkable ability to produce variants that can evade “natural immunity” as well as vaccine-induced immunity.
In light of Dr. Amerling’s article, I thought I’d go back and look at that AAPS article from 2000 to which I linked above, entitled The Tyranny of Public Health. In it, Jacob Sullum of the AAPS went after, of all things, smoking and the Clinton-era Healthy People initiative:
Given that expectation, it may seem rude to ask why, exactly, smoking is a matter of “public health.” It’s certainly a matter of private health, since it tends to shorten one’s life. But lung cancer, heart disease, and emphysema are not contagious, and smoking itself is a pattern of behavior, not an illness. It is something that people choose to do, not something that happens to them against their will.
If smoking is a matter of “public health,” and therefore subject to government control, then so is any behavior that might lead to disease or injury. And in fact, public health officials nowadays target a wide range of risky habits, including not just smoking but drinking, overeating, failing to exercise, owning a gun, and riding a bicycle without a helmet. Even gambling, which has no obvious connection to morbidity and mortality, is a matter of interest to public health researchers.(2)
Sound familiar? Dr. Amerling is simply reinforcing something that I’ve pointed out for a long time. As I’ve long discussed, antivaxxers and antimaskers are really anti-public health in general. This is nothing new. This 22 year old article published by AAPS shows that. It’s also nothing new for cranks to attack EBM as fascistic, as Dr. Amerling did in a recent AAPS article, first claiming that doctors “have become so dependent on guidelines that they have lost the ability to problem-solve, to think critically, and to practice real clinical medicine” and then praising hydroxychloroquine-pushing quacks like Dr. Vladimir Zelenko and Didier Raoult before launching into a rant that made me laugh out loud:
EBM arrogantly claims for itself the mantle of “science,” but is actually pseudoscientific. It relies heavily on studies of large populations and therefore statistics, which are inherently unre- liable and easy to manipulate. It exalts metanalyses, statistical compilations of many studies, which can be created to support almost any pre-conceived idea.6 The vast majority of physicians are unable to understand, let alone deconstruct, the statistics used in most studies. The conceit of EBM is that the results of large population studies can and should be used to dictate treatment of individual patients. This is known as the ecological fallacy. There is never enough granular information in such studies to justify a one-size-fits-all approach to treatment.
EBM creates an arbitrary hierarchy of evidence, with RCTs and metanalyses at the top and clinical experience, insultingly called “anecdotes,” at the bottom. This is absurd on its face. The logical conclusion is that clinical experience is not needed to practice medicine! Just buy a guideline cookbook and go out there and heal! Well, perhaps that’s where things are headed.
This is what we in the biz call a straw man so massive that, were it set on fire, it could be seen from the International Space Station. No one—and I mean no one—says that clinical experience is not needed to practice medicine. There are always cases for which RCTs do not apply or apply very imperfectly. There are cases for which RCTs might not agree. Again, as I mentioned above, every EBM-based set of guidelines has exceptions, or, as I like to put it, loopholes so huge that a physician like Dr. Amerling could drive a truck of other treatment through it. Even so, that does not mean that physician can or should be able to do anything they want or that there are no wrong answers. Surely even Dr. Amerling must admit that there are certain courses of action for a given patient that are just plain wrong, not supported by evidence. Admitting that, he admits that there are standards in medicine based on something other than what individual physicians decide that the evidence shows.
Also, big surprise, Dr. Amerling has no idea what he’s talking about with respect to the ecological fallacy. As I’ve pointed out numerous times, ecological fallacy is not a trap of randomized clinical trials, but of epidemiological studies. In brief, the ecological fallacy involves thinking that relationships observed for groups necessarily hold for individuals, or, as Gideon Meyerowitz-Katz put it:
The basic idea of the fallacy is this: you cannot directly infer the properties of individuals from the average of a group. Sounds complicated, but what that means is that if you measure something about lots of people — say, height — you can’t take the average measurement as an indication of any particular person’s status.
There’s a really simple example of this to do with means, or averages. Imagine you’ve got two groups of ten people, A and B. Group A has an average height of 170cm, and group B has an average height of 168cm. If you randomly select one person from each group, who is more likely to be taller, someone from group A or B?
The intuitive reaction is to say that someone from A is going to be taller than B, because the mean height is higher. However, this is not necessarily true. You can have a mean height of 170cm caused by two 200cm giants and eight 162.5cm people, and a mean of 168cm with six 170cm people and four 165cm people. In this case, 80% of group A is shorter than everyone in group B, which means that you’ll almost always get a taller person in group B if you pick randomly.
In other words, the average of a group isn’t always representative of the individuals.
Randomized clinical trials are actually designed to overcome problems like the ecological fallacy. Of course, it is true that RCTs can be problematic when it comes to inferring what would be the best treatment for an individual patient, but what Dr. Amerling and physicians in AAPS aren’t about that. They’re about elevating the physician to an Ayn Randian “superman” and rejecting all restrictions on physician autonomy in the practice of medicine, purportedly for the good of the patient. AAPS embraces an Ayn Rand-style view of doctors as supermen and women whose unfettered judgment results in what’s best for patients and medicine. Basically, the AAPS view of a great doctor appears to be epitomized by the character Dr. Thomas Hendricks in the Ayn Rand novel Atlas Shrugged. In that ideological screed disguised as a novel, Dr. Hendricks was a surgeon who left society to join John Galt’s capitalist utopia of “makers” because there was too much government red tape and he “would not let them dictate the purpose for which my years of study had been spent, or the conditions of my work, or my choice of patients, or the amount of my reward.” Dr. Hendricks had also discovered a cure for all strokes but wouldn’t share his discovery with humanity because ordinary peons weren’t worthy of benefiting from his work and he wasn’t getting paid enough. He was a really swell guy, and to him doctors who “followed the herd” (you know, like those pesky standards of care based on evidence) were, well, sheep.
Dr. Amerling concludes by imploring his fellow doctors:
American Medicine has become unmoored from its scientific and ethical anchors. I implore physicians to reject the example of German doctors who joined the Nazi Party and to stop being tools of totalitarianism. Doctors must reclaim their soul.
Unfortunately for Dr. Amerling, it turns out that it’s not so much doctors who support public health who are the fascists supporting the tools of totalitarianism. Quite the contrary, in fact, so much so that I have to wonder if Dr. Amerling is engaging in some serious projection. I do fear that American medicine is being “Nazified,” but it’s not public health proponents who are responsible. It’s doctors like those associated with AAPS.