Gary Null’s Attack on SBM

Gary Null is a long time promoter and marketer of alternative nonsense. He promotes homeopathy, alternative cancer cures, sells supplements on his website, has promoted HIV denialism and the notion that vaccines cause autism, and is anti-GMO. He also really doesn’t like Science-Based Medicine (SBM) and skeptics in general. Of course he doesn’t – because we call him out on his pseudoscience.

Many of the charlatans we expose simply ignore us and continue to make their millions, but some, like Null, have chosen to go on the attack. He has done this before, nicely taken down by David Gorski. I suppose it’s my turn to respond to the latest hit piece by Null.

And make no mistake, this is a hit piece. In it Null accuses us, by name, multiple times of being mentally ill, of being part of a cult, of having conflicts of interest, of being a front group, and being apologists for industry. He also attacks the skeptical movement in general, completely misinterpreting internal debates about what the scope and focus of the skeptical movement should be. But mostly he harps on the idea that we are narrow-minded “nihilists”. The article can be charitably called a rant, and in it is a Gish-gallop of misdirection and misconceptions. I cannot address everything he gets wrong (that would take a rather long series of articles) so I will focus on his more philosophical points about skepticism and SBM itself.

He portrays modern skepticism this way:

Although Skepticism has been a worldview dating back to the nineteenth century, today’s Skepticism is far more radicalized. Because Skeptics believe they represent the pinnacle of scientific materialism, many of the movement’s celebrity gurus feel they are the entitled saviors to redeem modern civilization from thousands of years of past history when human societies utilized medicinal plants and ancient mind-body practices to treat illnesses and the role of religion, spiritual practices, faith and belief to promote a sense of well being and psychological wholeness. As with so much of our dysfunctional postmodern world, Skepticism is therefore a natural outgrowth of white-dominant, patriarchal entitlement that continues to plague postmodern society. It is another perversion of identity politics however disguised under the banner of science.

Not quite. Actually I personally, and SBM collectively, represent a branch of activist skepticism that explicitly does not oppose religion per se, or faith or spirituality. We simply feel that faith should be properly treated as a personal choice, and not imposed on others or on society. We also feel that the medical profession should be based on science, and not on faith or spirituality. Faith is too personal and subjective to form a basis of medicine, and professional ethics argue strongly against health professionals imposing their faith on patients. The nature of science is such that we can use objective evidence and logic to form a consensus. The same is not true of faith.

We also may oppose bad choices, such as parents withholding basic medical care from a sick child, that are justified by faith (but regardless of the justification). We don’t attack the parents’ faith, but rather their imposition of that faith on a sick child that should be their responsibility to care for. It seems like this is all far too much nuance for Null, or more simply he is motivated to attack his simplistic straw men of our positions rather than truly understanding them and treating them with even minimal fairness.

He finishes that opening paragraph with a flourish about “white-dominant, patriarchal entitlement” while simultaneously accusing us of “identity politics”. This is a common false accusation by pseudoscientists – trying to portray science itself as a white male institution, therefore defending science is defending white patriarchy. Of course this stands in stark contrast to the reality that science is perhaps the only institution that is based on principles that are explicitly open, objective, transparent, and universal. There is no “white” science or “Western” science – there is just science. Of course historically science has been abused, like every institution has been abused, to serve those in power. That is an indictment of our societal ills, not science itself. But again, it’s easier to confuse than to enlighten.

And now we come to the meat:

In principle, Science Based Medicine largely supports Evidence Based Medicine. And to their credit, SBM’s foremost spokespersons Steven Novella and David Gorski opening criticize EBM’s shortcomings, including the now epidemic of erroneous research being published in medical journals, the increasing trends in professional bias in order to reach positive results, and journals’ financial incentives to publish junk studies. However, considering EBM’s flaws and failures, SBM perceives itself as the next great leap for modern medicine in order to establish scientific consensus on medical discovery and therapeutic practices by including the plausibility principle. Repeatedly, without any sound understanding for why a certain alternative health therapy either succeeds or fails, Skeptics invoke plausibility as the only necessary criteria to discard outright non-conventional practices and therefore to advocate against funding research to investigate any promises they may hold.

Null, it seems, feels he has to acknowledge that SBM criticizes mainstream scientific medical practice, because we so clearly and often do. In fact, the charlatans like when we do this because they can twist our healthy criticism into a nihilistic denial. He doesn’t realize, or want to admit, however, that this simple fact contradicts pretty much the rest of his screed against SBM as being a tool of that same mainstream institution. He simply ignores the glaring self-contradiction he has set up. If we are the tool he says we are, why would we spend so much time nitpicking about p-hacking, Bayesian analysis, and medical journal editorial policy?

In fact, further down he says:

If SBM would put more attention on the serious health risks of just a single common over the counter drug, acetaminophen or Tylenol, imagine how many people it would save compared to its fear mongering about supplements such as Vitamin C and Omega-3 fatty acids.

This was a poor choice of an example. Apparently Null was too lazy to do a Google search, for if he did he would have found a 2014 article by Harriet Hall: “Tylenol May Not Be As Safe and Effective As We Thought“. Oops. This was not a huge coincidence befalling Null. We regularly take on common misconceptions, whether they deal with mainstream medicine or so-called alternative medicine. Just within the last week Clay Jones wrote an article entitled “Think Twice Before Giving Young Children Reflux Medications“.

But of course we spend more time addressing fringe claims. That is our niche. There are plenty of mainstream medical outlets dealing with conventional medicine. There is a paucity of hard scientific examinations of fringe medicine, and that is a role we very deliberately fill.

But that is only part of our mission. Our core mission is to promote the process of SBM in all of health care. Of course the pushers of fringe and bizarre treatments don’t like that, because when you shine the bright light of science on their claims they don’t do well. But let’s get back to the plausibility principle, that Null (and others) like to attack. Again, Null misses all the nuance, despite the fact that we have written extensively on this topic and provided all the nuance for him. So let me do it again.

Of course proponents of fringe treatments hate the concept of plausibility, because their treatments are often highly implausible. That would love nothing else than to discard the idea entirely, and that, of course, was EBMs unintended mistake. So they portray the concept of plausibility as nothing more than bias and narrow-mindedness. But this is patently not true.

First, I think we have made a strong case that you have to consider prior plausibility when evaluating the clinical evidence. Clinical evidence is often not definitive, and so we have to put it into the context of plausibility. Moderate clinical evidence for a highly plausible treatment is not the same for moderate clinical evidence for a highly scientifically implausible treatment. Even from a purely statistical point of view, the probability of the former treatment working is far greater than the latter.

Further, we simply advocate a holistic (if you will) approach to the evidence. We suggest we should be looking at all the scientific evidence systematically, and put that evidence into the clearest scientific context possible. We have to consider the relationship between rigor and outcome, replicability, evidence for p-hacking, publication bias, and citation bias, take into account the decline effect in research, and compare clinical outcomes to overall plausibility. We do not, as Null would like you to believe, use plausibility alone as the sole reason to reject a new hypothesis.

Further, we do not require an understanding of mechanism of action to accept a treatment (although it helps put the evidence into context). It’s possible for clear-cut home-run clinical evidence (multiple independent large rigorous clinical trials showing a clear and consistent result that is statistically and clinically significant) to exist in the absence of known plausibility. In such a case, scientists would then try to reverse engineer how such a treatment works in order to fill in clear gaps in our knowledge.

But what we often have with the types of fringe treatments that Null champions, like homeopathy, is very low scientific plausibility combined with low quality studies, or clinical studies that are generally negative and never reach a reasonable threshold of acceptance. With homeopathy, for example, even if you ignore prior probability, the clinical evidence is simply negative.

Null then attacks us for saying that further clinical research is unnecessary. He misrepresents what is my explicit position. It’s OK to invest in research in highly unlikely treatments, but our research dollars should be proportionate to plausibility. This is not just my position – this is the position of the NIH and most funding agencies. You have to show there is a reason to think that your intervention is safe and effective before they will give you money.

Further, there have been over 1,800 studies in homeopathy. Homeopaths have had two centuries and hundreds of studies to demonstrate whether homeopathy works, and they have failed to do so. The simplest explanation for this is that homeopathy doesn’t work, which is further consistent with its low plausibility. I don’t see how you can make the case for doing still more clinical research into this dead hypothesis. At some point it becomes unethical to subject people to research on failed treatments.

Again, this is all nuance (but clearly stated nuance) that Null ignores in order to create his straw man that we reject ideas we don’t like out of hand.

You may notice I am just a couple of paragraphs in, and already this is one of my longer articles. The distortions and false claims keep coming from Null, but hopefully this will give you an idea of the intellectual value of his arguments (which are homeopathic).