“You cannot reason people out of positions they didn’t reason themselves into.”
— Ben Goldacre, MD
Dr. Ben Goldacre is the author of the popular Guardian column, Bad Science. He has recently published a book by the same name. Bad Science received a very favorable review from the British Medical Journal and although I was tempted to write my own review for Science Based Medicine, I decided to cherry pick some concepts from the book instead. I hope you’ll enjoy the cherries.
Honesty & Placebos
As you can imagine, any good book about bad science must devote at least one chapter to the concept of placebos. We are all quite familiar with placebos, and how squarely the vast majority (and some would argue all) of complementary and alternative medicines fit into that category. Ben surprised me with a couple of points that I hadn’t considered previously. Firstly, that alerting patients to the fact that you’re planning to prescribe them a placebo does not necessarily negate its effects, and secondly that no matter how skeptical or intelligent you are – all humans are subject to placebo effects.
Ben references a 1965 study from Johns Hopkins [Park et al., Archives of General Psychiatry] in which patients were explicitly told that they were going to receive a sugar pill (with no medicine in it at all) as treatment for their neuroses. The researchers reported substantial improvements in many of the study subjects’ symptoms.
This is the script that the physicians were to use to explain the placebos to the study subjects:
Mr. Doe… we have a week between now and your next appointment, and we would like to do something to give you some relief from your symptoms. Many different kinds of tranquilizers and similar pills have been used for conditions such as yours, and many of them have helped. Many people with your kind of condition have also been helped by what are sometimes called ‘sugar pills,’ and we feel that a so-called sugar pill may help you too. Do you know what a sugar pill is? A sugar pill is a pill with no medicine in it at all. I think this pill will help you as it has helped so many others. Are you willing to try this pill?
Wow. I was under the impression that the efficacy of the placebo was in the person’s belief that it was a legitimate medicine/therapy. Perhaps it only matters that the prescribing physician believes it might help? Perhaps snake oil salesmen are wasting their time on linguistic and pseudoscientific mental gymnastics?
Of course, the “gymnastics” do help. Other research has shown that the more complex the associated placebo ritual, the more potent its effects (such as piercing the skin with fine needles in many different locations). Nonetheless, I was surprised that an honest and accurate description of a placebo does not necessarily negate its effects.
We’re All Placebo Responders
My second surprise was that no one is immune to placebo effects. My pride wanted to assure me that I was above being hoodwinked, but alas, Ben explained that we humans are all potential placebo responders. Does packaging and marketing language influence your purchase decisions? Then you’re a placebo responder. Ben carefully described the role of packaging and marketing for the cosmetic industry – and I sheepishly had to admit that I have fallen for some of it.
About Liars vs. Bullsh*tters
Placebo peddlers are not necessarily liars. This is a subtle distinction that I hadn’t made before. Ben helped me to understand that alternative medicine practitioners aren’t necessarily offering therapies that they know are outright pseudoscience. Rather,
The liar knows and cares about the truth, but deliberately sets out to mislead; the truth-speaker knows the truth and is trying to give it to us; the bullsh*tter, meanwhile, does not care about the truth, and is simply trying to impress us.
Ben goes on to quote the philosophy professor Harry Frankfurt (from his 1986 essay “On Bullsh*t”):
[The bullsh*tter] is neither on the side of the true nor on the side of the false. His eye is not on the facts at all, as the eyes of the honest man and of the liar are, except insofar as they may be pertinent to his interest in getting away with what he says. He does not care whether the things he says describe reality correctly. He just picks them out, or makes them up, to suit his purpose.
I hope that distinction was helpful to you. I know I’ve mistaken many bullsh*tters for liars in the past. I’ll be glad to label them more correctly in the future. Dr. John is first on my list.
The Prevalence of Woo in Britain vs. the US
My final learning point for this blog post is that, as egregious as American woo is, Britain does seem to be farther along the path to utter surrender to pseudoscience. When I see Sanjay Gupta and Nancy Snyderman teaming up to sell home stool sampling kits for diagnostic purposes, then I’ll know that all hope is lost. Until then, I still feel a sense of pride in the general sensibleness of our medical leaders and spokespeople. Please don’t anyone dissuade me of that potential illusion.
Anyway, you should really pick up a copy of Bad Science to make yourself feel a tiny bit better about US healthcare. Apparently, the school curriculum in Britain encourages children to “massage their carotid arteries through their rib cage” to enhance oxygenation to the brain. Meanwhile, the British government is asking nutritionist Gillian McKeith to advise them on national food policy. Of course, Gillian says that we should eat more dark green vegetables because their chlorophyll will help us create oxygen for our bloodstream, and that she can sense organ toxicities through a light touch of anyone’s abdomen.
Feel better now, my American friends?