Shaping Opinions About Science and Medicine

The alternative medicine industry has been remarkably successful in shaping public opinion about the nature and relationship of science and medicine. A half century ago much of what is now considered by the public to be a valid alternative, or something that should be “integrated” into mainstream medicine, was considered to be health fraud. Like any complex social phenomenon, some of this rebranding was deliberate and calculating, and some emerged spontaneously from the community. The result has been a set of specific misinformation about science and medicine that works together to undermine the scientific position and promote quackery as legitimate.

I was recently sent this editorial, which nicely summarized that very position, and asked to comment. It is from a local news outlet in Alexandria, MN, but it could have easily had appeared in a big city newspaper, and I have encountered some version of this position countless times. The headline nicely encapsulates this position – “It’s Our Turn: Proof vs. possibilities”. The phrase, “It’s our turn” clearly stakes out the personal freedom and empowerment position that is common among so-called CAM proponents. It is the second part, however, the “Proof vs possibilities” that is the core of the piece, and represents a false dichotomy and significant misinformation at the heart of CAM apologetics.

The false dichotomy is the notion that mainstream medicine is too demanding and unreasonable when requiring scientific proof for treatments, while being hostile and dismissive of the possibilities of treatments outside the mainstream. This is a powerful narrative, but it is all nonsense. It is, to be honest, partly a manifestation of the Dunning-Kruger effect. The author appears to be writing from the illusion of knowledge, while demonstrating they don’t actually understand how modern medicine operates. As is often the case, there is a small kernel of truth lurking deep within some of his points, but they are distorted beyond recognition to serve a narrative that has evolved to promote a brand.

So let’s tease apart his specific points, which will be familiar to anyone engaged with science-based medicine, and examine them. He writes:

But it’s not easy staying healthy, especially when you consider all the contradictory and confusing health advice out there. One expert tells us to do one thing and another tells us to do another. Sometimes it works, and sometimes it doesn’t.

This is a clever way to dismiss or at least downplay expertise. Those experts often disagree with each other, so we can’t trust them. This is part of “The Death of Expertise” that has been marshaled increasingly recently in service to all sorts of unscientific positions. It is also a common strategy of the doubt and confusion used by science deniers. I am not saying that the author is a denier, just that this is a common anti-science strategy. Again – there is a kernel of truth here. Experts don’t always agree, especially in complex areas where our knowledge is limited. That does not mean, however, that there is always a lack of consensus.

Some scientific and even medical knowledge is very well established, and experts will therefore tend to agree (and the majority of health advice is actually pretty simple). I am often the second or third opinion for the patients I consult on, and they often tell me that my opinion is exactly what the previous neurologists also told them. Sure – because it’s the well-established standard of care. Also, sometimes differing opinions amount to nuance, or equivalent valid alternatives, or different ways to balance competing interests. Medical experts can make different recommendations, but both still be essentially correct or practicing within the standard of care.

Experts will tend to disagree when the science is unclear and opinions hold sway. Different specialists may also disagree because they have different sets of expertise. In my experience, the source of “disagreement” is mostly just a misunderstanding on the part of the patient. Another specialist may have referred a patient to me to see if a patient has a condition, not because they thought he does have the condition. And of course experts don’t know everything and sometimes one or more are just wrong. This may be because the community is wrong – we just don’t have the knowledge – or it may be because that one practitioner lacks information or made a mistake.

So valid experts usually do agree, and when they seem to disagree there are a variety of complex reasons. But you can easily wash over all this complexity to create doubt and confusion about the legitimacy of experts or expertise itself.

One of the most mind-boggling aspects of modern medicine is its scepticism and dismissal of anything that is not part of the mainstream medical establishment.

At first glance that may seem logical, because we think medicine is supposed to be based on science.

There is nothing mind-boggling about skepticism toward unscientific or implausible treatments. This is because modern medicine is supposed to be based on science. But the key to his statement is the word “dismissal”. CAM proponents try to dismiss the skepticism of scientists as being dismissive, when it isn’t. If anything, I am critical of my colleagues for not being skeptical enough. They are anything but dismissive – they tend to be very open, even to a fault. This is simply part of the anti-science narrative, and it is not based on reality.

We have very specific logic and evidence-based reasons to conclude that most CAM treatments likely do not work. Characterizing a vast body of scientific research and careful science-based analysis as being “dismissive” is absurd, but that charge will never go away.

The problem is, medicine doesn’t always work that way. Not only is the diagnosis often inconclusive, but the treatment tends to be a drug that has uncertain side effects and often only treats symptoms and not the root cause. In addition, everyone is different and reacts to drugs differently, which makes medicine sometimes seem less like science and more like grasping at straws.

This is the “science doesn’t know everything” defense. Yes, medicine is complex, everyone is different, and we are basing decisions on statistical information. That reality is not incompatible with taking a rigorous scientific approach to medicine. It is also no different for any treatment, whether you consider it CAM or mainstream. It’s not as if CAM proponents are practicing in a different world where patients are not all different. But as is often the case, the point of such comments is not to create a coherent position, but to maximize doubt and confusion over the scientific position. It’s all chaos, so you might as well go with your feelings, and our treatments feel better.

Also notice the very common tropes that mainstream medicine is all about drugs, and that we mostly treat symptoms. Again – these are not based on reality, just pro-CAM propaganda. Scientific medicine is the only medicine which makes a specific effort to understand and treat actual causes of disease. No CAM treatment does this – because they are not based on an actual understanding of biology. Some are based on false or superstitious notions of health and illness. Others are explicitly symptom-based. Homeopathic provings, for example, are all based on symptoms. So accusing modern medicine of treating symptoms is flipping reality, but it is amazing how many people buy this.

What is also interesting is the inconsistency of this position. When we point out that CAM treatments do not address the cause of a disease and in fact have only placebo effects, then suddenly symptomatic treatment is fine. It’s the best – it improves quality of life and is patient-oriented. I have never seen this blatant double standard give a CAM proponent a moment of pause.

Doctors have a tough and important job and we shouldn’t expect miracles from them. But we should expect an openness to possibilities. Certainly there is science involved in medicine, but there is also practicality, intuition and experience. Just because something has not been proven with science yet doesn’t mean it isn’t true and couldn’t be useful to some people.

The author is trying desperately to seem reasonable, but every concession is immediately taken away. Again, this is a false dichotomy. You can be open to possibilities but also require rigorous science to test those possibilities. That is, in fact, exactly what scientific medicine is. We are, in fact, maximally open-minded. All claims are treated with an equal requirement for logic and evidence. It is the CAM proponents who are closed-minded. They are closed to the possibility that their preferred treatment does not work. No amount of evidence will convince them. They will dismiss anything that contradicts their position, and simply move on. I have an open challenge to anyone to point to a CAM modality that has been largely abandoned because evidence showed it does not work or is not safe. I am still waiting.

Physicians also don’t ignore practicality, intuition, and experience. If anything the evidence shows that we rely too heavily on these things, to the detriment of our patients. This is the whole point of evidence-based medicine, in fact. Patient outcomes are objectively better when we put evidence first. Experience and intuition (which is mostly just pattern recognition) are very helpful. They are great at generating hypotheses, but we can’t end there.

In fact, the complex relationship between intuition and analytical thinking in clinical decision making is something which is specifically studied and taught. This is again a great example of Dunning-Kruger – there is a deep and thoughtful literature dealing with intuitive vs analytical thinking in medicine, yet the author thinks they can criticize an entire profession from a position of apparently absolute ignorance about this topic.

The problem is that while medical science has no problem “proving” that an expensive drug will “safely” treat a particular symptom, it seems to have trouble telling us how much of a certain vitamin we need, or what types of food we should eat, or how to prevent disease. Worse yet, when it comes to alternative medicine, with treatments that seem to help some people, traditional medicine can be downright hostile.

The author flirts with the “Big Pharma” conspiracy throughout, implying here that we marshal our science only to prove that expensive drugs work. I will acknowledge the kernel of truth here that the pharmaceutical industry itself is largely geared toward this, but not all of medicine. There is plenty of public, private, and academic research independent of pharmaceutical companies. Doctors also use many treatment modalities other than drugs.

Why the author thinks that scientific medicine has difficulty telling how much of a vitamin people need is truly astounding. Science discovered that vitamins exist, and determine their nature, what they do in the body, what happens when we don’t get enough, and has explicitly determined within very narrow tolerances exactly how much people need. I am struggling to determine what he is even referring to, unless it is simply just more doubt and confusion generated by the supplement industry to promote unneeded megadoses of their products.

Regarding the last point, I wish mainstream medicine were more hostile toward quackery. Sadly, that is not the case. What SBM recommends is also not best characterized as hostility, but rather we simply advocate a clear and consistent standard of science and evidence to determine the risk vs benefit of any intervention. That’s it – one honest and rational standard that properly balances all interests. But it’s easy to distort this position into being “hostile” and “dismissive” when your pet theory or treatment does not survive honest scientific inquiry.

One more:

There seems to be a double standard at work here. On one hand, new drugs are approved and condoned if they appear to be safe and effective. On the other hand, herbal medicines (which are not backed by huge drug companies) are expected to prove with 100 percent certainty that they always work and are invariably safe.

This is where he goes off the rails (not that he was really ever on them). There is a double standard, but it does not work the way he claims. Drugs have the highest standards of evidence for any medical treatment. That is undeniable. The FDA requires multiple studies showing safety and efficacy, and regulates the rigor and execution of those studies closely. The system is not perfect, but it is a relatively high bar that costs tens to hundreds of millions of dollars of research to cross.

Herbs, on the other hand, have largely been deregulated (despite being essentially just dirty drugs, when they aren’t actively adulterated or contaminated). You can put an herb on the market with zero research, as long as you don’t claim to treat a disease. I wonder if the author would like to have pharmaceutical drugs and herbal drugs trade regulatory places. Or perhaps, we could just require the same bar of evidence for herbs as we do for other drugs. Deal?

I also have to wonder how they came to the conclusion that anyone is asking for “100 percent certainty” of safety and effectiveness for herbs. Where does that even come from? They seem to have made up that point out of whole cloth – but it does serve the narrative. That is a classic strawman, and I would challenge him or anyone else to point to a reference to justify that accusation.

How about we acknowledge first that herbs are drugs. Thousands of years of use does not, in fact, guarantee that they do anything (see all of prescientific medicine for a reference) or even that they are safe. Also, many modern herbal products are fairly recent, and the claim to antiquity is just marketing, or at least extremely misleading (they were often used for many vague indications, and often different from what is currently being claimed). We can dispense with the health halo, the “natural” marketing, and just treat them like drugs. Require basic testing for safety, and only allow claims based on adequate evidence.

As you can see, it takes far more time and space to correct misinformation than to create it (this is known as the Gish Gallop, after famous creationist Duane Gish who favored this strategy).