FALSE-DICHOTOMY-copyIn a recent editorial for the New York Times, Aaron E. Carroll argues, “Labels Like ‘Alternative Medicine’ Don’t Matter. The Science Does.” I agree with this headline thesis, but the details of his argument ironically show the harm that the so-called CAM (complementary and alternative medicine) movement has done.

Carroll starts out well, essentially pointing out that the division between “conventional” and “alternative” medicine, and the division between “Western” and “Eastern” medicine are false dichotomies. Despite this strong start, he muddles his way through the rest of his editorial.

The primary error he commits is to swing from a false dichotomy to a false equivalency, essentially saying that there is no difference between conventional and alternative practice or practitioners. In order to support this contention, however, he has to distort the facts beyond recognition.

In other words, Carroll commits the less-well-known false continuum logical fallacy. Let me explain.

The real differences between SBM and CAM


I agree, and it is a central thesis of SBM, that the category of CAM (whether you call it holistic, alternative, complementary, or integrative medicine) is a manufactured and misleading one. In this way it is false, but not in the sense that Carroll takes it, meaning that it doesn’t exist.

Rather, medical treatments, claims, diagnostic procedures, and even concepts of disease and health exist on a scientific spectrum, from rock solid at one end, to completely disproven and utterly absurd at the other.

Conventional medicine attempts to be science-based, and has an infrastructure designed to maintain high scientific and professional quality. But still, this is a challenging and complicated goal. Acceptable components of mainstream medicine therefore range down the spectrum of science to the gray zone, and different people and institutions will draw the line of acceptability in different places.

The philosophy and goal of SBM is to examine this very question – how do we best use logic and evidence to determine where a medical claim is on that spectrum, and how do we know where to draw the line?

CAM exists in that it is a definable approach to this issue that is distinct from mainstream medicine. We explore this at length in the pages of SBM as well. I think we have clearly established here that it is fair to say CAM practitioners in general will use treatments anywhere along the scientific spectrum with little or even no regard for logic or evidence. Further, they are actively trying to weaken and muddy the scientific and academic standards of medicine and the regulations that maintain them (with an unfortunate degree of success).

While CAM may not explicitly be a set of practices, it is a definable set of behaviors that are decidedly unscientific. The CAM approach consistently leads to the same set of practices, like homeopathy, herbalism, energy medicine, and acupuncture, that are not scientific.

The false equivalency

Carroll, while he seems to sort-of get it when it comes to the false dichotomies promoted by advocates of CAM, misses these very real distinctions.

He correctly points out that:

People often think of Eastern or alternative medicine as more “natural.” Many feel that Western medicine is built around technology and products produced in a lab. They’re not entirely wrong. Many of the gains that have been made in traditional medicine have been the result of innovation in laboratories.

But that doesn’t mean that everything doctors are taught in medical school involves a drug or device. I talk to patients all the time about diet and exercise.

I agree – “natural” is a false distinction. What is “natural” about claiming to manipulate non-existent energy, or sticking needles into people? He also correctly points out that nutrition, exercise, physical therapy, and relaxation are all science-based components of mainstream medicine, which is not all drugs and surgery.

Carroll, however, goes off the rails in two important ways. First, he struggles to find CAM modalities that have been validated by science. His examples are all terrible, and in fact demonstrate how scientifically vacuous CAM really is. Even someone dedicated to finding the best examples of science-validated CAM can’t really do it.

He argues that acupuncture is now evidence-based, referring to the infamous Vickers review and concluding:

They found that not only did acupuncture work better than no-acupuncture control groups, but there were also significant differences between acupuncture and sham acupuncture. This suggests that not all of the benefits are placebo effects.

This only demonstrates how far the standards have fallen, especially when considering a CAM treatment. If acupuncture were a drug, with the exact same level of evidence, it would be attacked as a Big Pharma conspiracy.

David Colquhoun and I did our own review of acupuncture, and point out that the most rigorous studies are all negative, no effects are adequately replicated, and the so-called positive effects from meta-analyses such as Vickers are so razor thin that they are clinically insignificant (meaning explainable by even subtle bias or methodological flaws). The best conclusion we can make from thousands of studies is that acupuncture points don’t exist, that it does not matter where (or even if) you stick the needles. In other words, the only scientifically valid and consistent conclusion based on thousands of studies is that acupuncture is little more than an elaborate placebo.

Carroll also mentions several herbal treatments. Herbs, as we have pointed out numerous times, are drugs. A treatment effect is therefore plausible. Herbs are the low hanging fruit of CAM when it comes to scientific plausibility. And yet here too his examples are mostly dubious, with the evidence being weak and contradictory. Orac addresses these specific claims in his own post, so I won’t repeat them here. Carroll also glosses over the many fatal problems with the supplement industry that make it nearly impossible to apply herbal products in medical practice.

The second way in which Carroll goes off the rails is to completely, in my opinion, mischaracterize how mainstream vs CAM practitioners respond to evidence. He makes an explicitly false equivalency argument. After reviewing the evidence that homeopathy does not work, he states:

My friends who believe in homeopathy don’t really care.
Those who favor conventional medicine, though, can be just as blinded. Too often, when confronted with evidence that advanced technology might not be providing benefits, the medical community refuses to change its behavior.

Saying that mainstream doctors are “just as blinded” to evidence as homeopaths might be considered defamatory. This statement is so divorced from reality it is hard to imagine how Carroll came to this conclusion. It seems to me he had his thesis – that of the false dichotomy – which he misinterpreted as meaning there must also be an equivalency, and then motivated reasoning kicked in.

Keep in mind, much of what we do here at SBM is advocate for higher standards of evidence within mainstream medicine, and we are quick to criticize the slow adoption of evidence-based standards. In the end, however, mainstream medicine listens to the science. It is slower and messier than optimal, by far, but the philosophy and culture is ultimately science-based.

Homeopathy, on the other hand, is completely divorced from science, and is in fact completely pseudoscientific. Their basic principles violate everything we known about physics, chemistry, and biology. They have stuck to their pre-scientific guns despite two centuries of scientific advance. Their claims are indistinguishable from magic formulas and witchcraft, and no amount of evidence of lack of efficacy will dissuade them.

This creates the sense that while Carroll may be familiar with the shortcomings of mainstream medicine and with science in general, he is largely naïve to the realities of CAM. We find that this is generally true outside of SBM, part of which is specific expertise in medical pseudoscience.

This is true more broadly as well. Scientists do not necessarily possess specific knowledge or expertise in the nature and details of pseudoscience. Such expertise is the purview of scientific skepticism, of which SBM is definitely a part. Carroll’s editorial is a dramatic demonstration of the pitfalls of scientists lacking expertise in pseudoscience while commenting on it.

Conclusion

A thorough and fair assessment of CAM leads one, in my opinion, to the ineluctable conclusion that CAM as a category is counterproductive. In practice it is a marketing term, the purpose of which is to lend false legitimacy to medical practices that were once considered fraud and pseudoscience. It is a banner beneath which proponents seek to weaken the scientific standards of medicine, foment confusion as to the nature of medical practice, treatments, and evidence, to infiltrate academia, and to lobby for weaker regulations.

In short CAM is a scam. It should be abandoned, and the medical profession should re-dedicate itself to an uncompromised standard of high quality science.

Posted by Steven Novella

Founder and currently Executive Editor of Science-Based Medicine Steven Novella, MD is an academic clinical neurologist at the Yale University School of Medicine. He is also the president and co-founder of the New England Skeptical Society, the host and producer of the popular weekly science podcast, The Skeptics’ Guide to the Universe, and the author of the NeuroLogicaBlog, a daily blog that covers news and issues in neuroscience, but also general science, scientific skepticism, philosophy of science, critical thinking, and the intersection of science with the media and society. Dr. Novella also contributes every Sunday to The Rogues Gallery, the official blog of the SGU.