Back in episode #401 of the SGU we talked about a recent survey of “smart people” who were asked, “What Should We Be Worried About?" In our discussion we each gave our own answer, and mine was this – I worry that nonsense, pseudoscience, and mysticism will become institutionalized in such a way that it will take literally decades or even centuries to undo the damage. It’s like a toe fungus; once it is established, it is almost impossible to get rid of.
Just take a look at something like homeopathy. Homeopathy, which uses potions that are mostly diluted past the point that any active ingredient can remain, is literally a completely worthless pre-scientific system of medicine based upon demonstrable pseudoscience. Its core principles are little more than witchcraft, and its nostrums do not work. Yet, homeopathy has survived for over two centuries and will likely continue to survive for the foreseeable future.
If you compare homeopathy in different countries, there appear to be two dominant factors that influence its acceptance and use – cultural acceptance, and institutional support. In the UK, for example, there are homeopathic hospitals. In the US homeopathic products are automatically FDA approved, bypassing the requirement to provide any evidence of safety or effectiveness.
This is precisely why we need to be cautious before erecting an infrastructure around a new idea or concept. That infrastructure will tend to persist, out of sheer momentum; long after the idea itself has been shown to be wrong, useless, or counterproductive. This is partly why scientists tend to be so conservative.
The world of medicine does tend to have a problem with prematurely adopting and supporting new ideas and treatments before the science is in. This is understandable to some degree. Medicine is an applied science. We are used to making practical decisions about management in the absence of perfect scientific knowledge. While we emphasize avoiding harm in our decision-making, not doing something is a decision and can have consequences. Also, there is a great deal of pressure from patients who only want solutions, and who tend to prefer doing something rather than nothing when they are suffering.
The deal we have made with ourselves is that we may get ahead of the evidence at times (which we justify as being compassionate to our patients), but when the science does come in, we will abandon treatments that do not work. These are called medical reversals, and they are critical to the scientific basis of medicine.
A recent survey of published articles in one high-impact journal over the last decade found that 40% of published papers that questioned the effectiveness of a treatment already in use resulted in medical reversal. The authors suggest that this is too high, and therefore we need to become more conservative before adopting new practices. This does not mean, incidentally, that 40% of medical practice is wrong. The published studies would tend to focus on questionable treatments (that’s why they are being studied), rather than more solid and established practices. Further, physicians will tend to use more established treatments preferentially over less well-established ones. In any case, the study is interesting and does suggest we may need to be more conservative, if anything, or at least reexamine the thresholds of evidence necessary to recommend a treatment (in line with what skeptics and science-based medicine advocates have been saying for years).
I always marvel at the irony, however, of the constant push within mainstream medicine to be more evidence-based, more science-based, and more scientifically rigorous and conservative, while at the same time proponents of so-called alternative medicine are pushing for decreasing scientific rigor, for loosening the standards of evidence, and weakening or even eliminating the science-based standard of care.
In addition to eroding scientific standards, they rush to institutionalize their ideas and treatments before any compelling validation, and they know nothing about medical reversals. My ongoing challenge to proponents is to name one alternative medicine modality that was condemned and abandoned following scientific evidence for lack of efficacy. I’ve been doing this for a long time, and I can’t think of one. (Sometimes the branding and marketing changes, but not the treatment itself.)
In the last two decades the institutionalization of unscientific medical methods and even entire systems has accelerated, fueled by profits and slick marketing. One distressing example of this institutional support recently came to my attention – the American Board of Physician Specialties now has certification in “Integrative Medicine.”. They list the topics for the certification exam, which includes things like energy medicine, homeopathy, shamanism, craniosacral therapy, and elimination diets.
These trappings of legitimacy matter, because they blur the lines between science-based medicine and medical nonsense. It seems undeniable that purveyors of worthless treatments will exploit people because the ABPS has essentially given their stamp of approval to pseudoscience.
There are those within the culture of medicine who are correctly pointing out that medical treatments need to be rigorously science-based, otherwise we risk violating our prime directive – first do no harm. The profession of medicine also has a contract with society, and that contract includes the promise of due diligence.
Applied science is hard, and we have learned a great deal about the many pitfalls of gathering and evaluating scientific evidence for a system as variable and complex as the human body. The funding, design, execution, peer-review, publication, evaluation, and application of scientific studies have to be examined carefully to root out error and systematic bias. The fruits of this evidence needs to be communicated to practitioners, and errors need to be corrected quickly.
The culture of alternative medicine violates all of these principles. They advocate for looser standards of evidence, for an anything-goes style of practice, and perpetuating error without limit or any mechanism of self-correction. They call this philosophy “alternative, ” “integrative,” “complementary,” “holistic,” and “patient-centered,” and promote it with calls for “health care freedom.” In reality it is simple pseudoscience and nonsense that exploits patients for profit and wishes to be unshackled by any regulations that would hold them to standards of evidence – because they cannot meet those standards of evidence. If they could they would be practicing medicine, and would not need any special exemptions or labels.
Steven Novella, M.D. is the JREF's Senior Fellow and Director of the JREF’s Science-Based Medicine project.