Tuesday, November 13, 2007

The Macho Response: Dr. Graham Sharpe Throws Down The Gauntlet ("Fascism It Is")


Pseudoscience and Quackery in New Zealand by Dr. Graham Sharpe

I will start by posing a question.

The question is:

What do you get of you cross a reflexologist with an iridologist?

You are required to to answer this by the end of this address.

Another question.

What exactly do you expect of me?

Or, to put it another way

Why ask me to give this presentation?

My views on alternative medicine are, I think, reasonably well known. Especially amongst my colleagues and friends. My opinions on this matter have at times got me into trouble, but usually only with politicians, quacks and other irrelevants – the usual suspects – but I’m not too worried about that.

Leona Wilson has, at a Medico Legal Society meeting, described my views as “somewhat opinionated” but she is quite wrong – and she knows it. My views are not somewhat opinionated at all.

My views are highly opinionated. And I make absolutely no apology for this.

Any view on this is by definition opinionated, because the whole field of alternative medicine requires an opinionated approach. It cannot be rationally debated because it is anecdotal opinion.

Not science. Not even medicine. But opinion, pure and simple.

So there can be no debate, no discussion, no engagement unless there is acknowledgement that alternative medicine is purely opinion, conjecture, supposition, assumption.

Alternative medicine does not even fit into the theme of our meeting, "Facts Fads and Folklore."

We would have to entitle it, "Fallacies, Fads and Folklore."

Yes it is fallacious, based on folklore, and is very faddish in its nature, but is extremely short on facts.

Calls for us to some how engage with this are growing, and such calls lead me to my view – alright my strongly opinionated – views. The growing popularity of alternative medicine has to be faced, and confronted. Dealt with, or should I say dealt to?

Dealing with alternative medicine means rigorously testing its claims.

Dealing with alternative medicine means exposing its scams, frauds, pseudoscience, delusion, and its shear muddle headed thinking.

Dealing with does not mean a softly softly, co-operative approach. It is not our ethical duty to trade with snake oil purveyors!

But before we go any further, let’s just digress and deal with some terminology.

The medicine which we practice is called a number of different things- particularly by our opponents

Conventional medicine

Western medicine

Traditional medicine

Allopathic medicine.

I contend that we should take back the terminology that is rightfully ours and say we practice medicine.

There is nothing conventional or traditional about modern medicine – it is continually evolving. Nor is it peculiarly western as such – that would deny the historical influence of, for instance, the great Arab physicians who were world leaders in medicine during the European dark ages.

Medicine is a system of healing and alleviating suffering based on scientific study, with definitions of disease and intervention, defined outcomes, appropriate analysis and, most importantly, with confirmation and replication of results by independent researchers. We may not meet all these requirements all of the time, but we strive to.

We can add extra words if we wish – scientific medicine or perhaps better scientifically based medicine. Or even evidence based medicine. But let’s for heaven’s sakes stop pussy footing around, and stand up for what we do.

We practice medicine.

Therefore there is no such thing as alternative medicine. Let’s be clear about that. There is medicine, and there are alternatives to medicine. Treatments are either medical or they are not. Alternative medicine is oxymoronic.

Why not alternative pathology or alternative psychiatry? Or alternative anaesthesia? Alternative surgery raises some interesting possibilities.

Do we accept alternative physics or mathematics? Should we have an alternative value of Pi? This actually happened in the United States in 1897 when Indiana legislated that Pi was to have a value of four, rather than pesky three point something long and complicated. Of course alternative maths leads to alternative engineering. Try building a bridge or a jet engine with Pi valued as four. Interesting thought!

Complementary medicine is similarly not valid or precise enough to be used. It is pure and simply a brand name, nothing else.

So for the purposes of this talk I will use the term “So Called Alternative Medicine” or SCAM for the sake of brevity.

How will I refer to SCAM practitioners?

To call them fraudsters invites a libel suit – and believe me they are very keen on that sort of thing. In the name of open debate you understand of course.

Calling them fraudsters also implies criminality – deliberate intention to mislead and exploit.

I actually do not think this is the case. SCAM practitioners on the whole do not knowingly mislead or dupe people. They genuinely believe in what they are doing – they are not fraudulent, nor are they classical charlatans. They are merely misguided, or perhaps deluded.

So for the purposes of this talk I will use the less value laden term “Quacks”.

Having established the terminology, we can look at SCAM in a broad sense. It now encompasses such a wide range of activities an all encompassing view is difficult, or even impossible. Also, SCAM permeates not just medical life, but political and social life as well. It gradually infiltrates mainstream society, in a manner mysterious to many of us. How is this happening?

There has always been interest in SCAM, but as we defeat the great medical scourges of the past, especially the infectious diseases, as we make life longer and more comfortable than ever before – and if you don’t believe me visit any older cemetery and see the graves of children killed by diphtheria, of mothers killed in child birth, of working men killed by occupational disease – as we make inroads into these scourges we observe a rise in a post modern reaction to science and technology.

This is resulting in a distrust of science and the scientific method. And such reaction displays a complete and profound misunderstanding of what science is.

Science is a way of thinking, a way of looking at the world, a way of interpreting what we observe and experience.

Brecht put it quite nicely:

“The aim of science is not to open the door to infinite wisdom but to set a limit to infinite error.”

For Karl Popper, what demarcates science is not support of theories by observation, but that theories are open to observational and empirical criticism and refutation, and that efforts are made to falsify the theory. So for Popper the only theories worth considering are those that can be falsified, and therefore are testable.

This is highly relevant in alternative medicine. The theory that all health is centred on the spine – the basis of classical chiropractic – is not falsifiable, so is not testable. Similarly the homoeopathic theory that “like cures like”. Unfalsifiable, therefore untestable.

Contrast this with medicine.

Penicillin kills streptococci in vitro and in vivo.

Insulin lowers blood sugar.

Falsifiable. Testable. Tested severely and found to be valid. Contrast that with the vast majority of alternative medicine claims!

Of course science is a human construct, and because it is human errors will be made.

Quacks point to such errors, or mistakes, such as the thalidomide disaster, as evidence of their own efficacy. But this is illogical. Medical mistakes, or iatrogenic medicine, do not of themselves give any validity to SCAM.

A better approach is

“If SCAM is the answer, what exactly is the question?” for this question demonstrates what we are up against. Was it Sun Tzu in “The Art of War” who said “first know thine enemy”?

SCAM now covers such a wide variety of claims – many of them contradictory and mutually exclusive – that a response is of necessity fractionated. And of course this is the divide and rule doctrine, for a fractionated response is a weak response. Hence our growing difficulty in countering SCAM.

Also, the multitude of claims allows a continual shifting of the goalposts, for example “Well you may have a point about homoeopathy but what about iridology etc etc.”

What we can and should meet head on are the common characteristics of SCAM. And I wish to deal with some of these. These are very much my own views, but if I have inadvertently plagiarised from others, I apologise.

These similar concepts usually end in the letters I S M. Isms. I call them the “Isms of SCAM.” Actually that would make a great movie title for George Lucas “Star Wars 172 – the Isms of SCAM.” My copyright George. All cheques to me thanks.

Some of these Isms are, I confess, somewhat contrived but they are good fun.

So, “The Isms of SCAM.

Vitalism.

Many SCAMs cling to this ancient concept. Life, particularly human life, relies on some unseen force, some vital energy. This force is totally unknown to physics, chemistry or biology. It remains totally unproven, and there is no rational reason to suppose it exists.


Vitalism is often expressed in terms of auras or energies,
or the chi of acupuncture and traditional Chinese Medicine. It is a basic necessity of homoeopathy, therapeutic touch and some forms of massage.

Vitalism may be expressed in a religious concept – the breath of life for instance. But SCAM claims to be science, not religion.

Naturism.

And I don’t mean “Naturalism” - frolicking around naked. I mean the view, childish view, that because something is natural it is good, or better than un-natural drugs and surgery. Vitamins are good because they are natural. Arnica is natural, therefore it is good. Digoxin is drug and must be bad, but fox glove tea is natural so is good. Similarly aspirin and willow bark extract.

OK so syphilis is natural. So is cancer, malaria. Even uranium.

The “natural” argument is spurious, and can safely be disregarded.

Romanticism.

The belief that there was once a golden age of health and vitality that has been ruined by modern medicine, and modern life itself. People were happier and healthier, life was kinder. There was hardly any cancer. People lived to ripe old ages. And doctors were nice people who sat by the bedside and did not charge money.

This golden era never existed. Again, visit an old cemetery. And think of life without, well, anaesthesia. Without modern dentistry. Without antibiotics.

This romantic view of the medical past is particularly evident in support for Traditional Chinese Medicine or Aruveydic medicine, an ancient Indian tradition. It also looks to ancient cultures such as that of the North American Native peoples, or even Atlantis.

Revelationism.

Many popular SCAMs have been started by an individual who has had some blinding thought or revelation. A Eureka moment.

Hahnemann and homoeopathy, Palmer and chiropractic, Peczely and iridology, Fitzgerald and reflexology, Bach and flower remedies. Or a more recent example Andrew Weil and stoned thinking.

Some essential truth has been revealed to an individual. Not by a rational process of inquiry and investigation, but by some sort of quasi religious or spiritual experience.

This results in what can reasonably be referred to as a cult, rather than a scientifically proven method of medicine.

Of course there have been Eureka moments in medicine, but the difference is that they are investigated by clinical trials or scientific experiments. Medical Eureka moments often fail when properly tested, and are then discarded. But sometimes, such as Fleming and penicillium mould on his agar plates, they are valid and new and exciting. But they stand up to scrutiny- proper scrutiny.

Post Modernism.

I accept my use of this term may not strictly accurate, as it arises out of architecture and sociology rather than science, but it is used to describe the thinking that we have moved past science, into a New Age. This thinking is gobbledygook, best demonstrated by a quote.

In his book, Supernature, Lyall Watson says the following:

Science no longer holds any absolute truths. Even the discipline of physics, whose laws were once went unchallenged, has had to submit to the indignity of the Uncertainty Principle. In this climate of disbelief, we have begun to doubt even fundamental propositions, and the old distinction between natural and supernatural has become meaningless.

Let’s just dissect this a bit.

No absolute truths? Here’s one – light travels faster than sound. This is true, and therefore an absolute. Discovered and proven by science.

What about a medical one. Oxygen is essential for human survival. Nothing relative about that. No oxygen, humans perish.

Post modern thinking leads to another ism:

Relativism.

This view holds that any point of view is just as valid as any other, or as Prince Charles calls it “Other ways of knowing”. This holds that if some one thinks something, that thought is as valid as any other. So if some one thinks homoeopathy cured their dog’s shingles, it did. Any view point is valid, and this is used to defend SCAM, and particularly to defend its use in public hospitals at public expense.

The basic flaw in this argument can be met with an example. Everyone used to think the sun revolved around the earth. Does this make the theory true? Or did the sun revolve around the earth when everyone thought it did, and has the earth started revolving around the sun because that is what we now think happens?

The relativism defence of SCAM more often than not ends with the statement that “everyone is entitled to their opinion.”

Well let’s just dissect that a little further.

I am an enthusiastic democrat. Democracy has many flaws, but no better system has yet been found. In a democracy, you have to tolerate opinions that differ from yours.

That does not mean however, that an opinion is as valid as any other. Nor does it mean that everyone is entitled to their opinion. To take an extreme example, some people have been of the opinion that Jewish people are vermin who should be exterminated. Are they entitled to that opinion? No. We now accept that opinion is dangerous and wrong. Some opinions are obnoxious, and are not deserving of tolerance.

This leads to my next ism

Epiphenomenalism.

This is a psychological term which refers to a confusion between cause and effect. For instance do we cry because we are sad, or are we sad because we are crying?

Also, epiphenomenalism is, for me, a new word, and even if I have not used it correctly in the strict sense, I was determined to include it some where!

Confusion about cause and effect is a basic feature of SCAM. Homoeopathy and dog’s shingles again. And this results in another ism of SCAM. Anecdotalism. All SCAM relies heavily if not totally on anecdotes to support its claims. Watch late night TV or look in a women’s magazine. Plenty of stories about coffee enemas curing cancer or ear candling curing autism.

This demonstrates a common logical fallacy. If A follows B, B must have caused A.

So if SCAM A is used and illness B is cured, SCAM A cured it.

Well why do people recover from most illnesses? Or why does SCAM appear to work?

Placebo. Especially in treatment of pain.

Cyclical disease. Popular with quacks. Many illnesses wax and wane with or without treatment.

Misdiagnosis. Or non diagnosis. Again popular with quacks, especially when given in terms of “weakness”. Weak liver. Weak immune system.

Psychosomatic Illness. The worried well, characteristic of modern Western life, and a great source of income for Quacks.

Spontaneous Remission. Even cancers occasionally remit with no obvious explanation.

Time. The great healer. A cold last seven days, unless you use homoeopathy, and then it will last only a week.

Considering the effects of SCAM in such a way is applying Occam’s razor. Seek the easiest explanation. If you hear hoof beats in the night, assume it is more likely to be a horse than a zebra.

Annecdotalism reveals itself in another way in SCAM circles. And this is reference to published material. Every so often a study is published in a leading medical or scientific journal which apparently supports a SCAM modality. These are few and far between, and of course are seldom if ever replicated by further studies. But the SCAM community shouts them to the roof tops.

Of course much material is published in SCAM’s own literature, but these are not credible scientific journals. They are better thought of as comics, but comics lacking in artistic or comedic merit.

Iconism.

By this I mean the use of so called celebrities to endorse SCAM.

Some of these should know better.

The late Linus Pauling – a double Nobel Prize winner no less – gave credence to spurious and wildly unlikely claims about vitamin C by his endorsement. This was given with no scientific evidence. He published a single observational paper but not one controlled trial. Not one. His claims that mega doses of vitamin C would prevent the flu or the cold, or even help cure cancer, remain totally unproven. At best vitamin C supplements may, and I emphasise may, reduce cold symptoms to some minor degree.

Linus Pauling aside, celebrities who endorse SCAM tend to be people with too much time on their hands, too much money, and not exactly noted for their intelligence. You know, film stars, rock stars, royalty. Whether it’s Prince Charles and homoeopathy, or Linda McCartney endorsing alternative cancer therapy, or Jerry Hall and her opposition to unnatural medicines, they can be, and should be, safely ignored.

The other problem with iconism is that if fellow travellers are a support for SCAM, less savoury fellow travelers must also be considered.

That well known vegetarian, non smoking, teetotaller, animal rights lover Adolf Hitler was an enthusiastic supporter of homoeopathy. He was also very keen on the weird anthroposophical medicine of Rudolf Steiner. I hasten to add that this does not make Steiner a Nazi – he died in 1925 and as far as I know he was not a Nazi or an anti-Semite.

I have struggled to find an ism for my next feature. But I can’t.

Fantastic Claims.

The basic claims of SCAM are simply fantastic.

Homoeopathy relies on serial dilutions of chemicals to the point where none of the ingredient is left. Dilutions of one in a hundred, done 125 times. A little simple maths shows this claim to be truly fantastic. Cosmologists estimate there are ten to the power of eighty molecules in the universe. So ten to the power of minus 125 is a stupendous number.

Iridology claims the iris reflects the health of all organs in the body. Another fantastic claim.

Similarly reflexology – the foot reflects the body.

Therapeutic Touch claims we can treat patients by not touching them, thereby manipulating the body’s auras or energy fields. A fantastic claim, refuted soundly by a nine year old girl Emily Rosa, who showed therapeutic touchers cannot detect energy fields, therefore how can they manipulate them.

Let’s consider an extraordinary claim from the world of alternative psychiatry.

It is claimed that a major cause of psychiatric illness is kidnap by aliens, often accompanied by medical experiments. Supporters of this claim say that as many as 3% of Americans have been kidnapped by aliens, all in great secret of course. There are about 250 million people in the States, so 3% means 7.5 million abductees, all since 1947. 125,000 abductions a year – or 2,400 a week – or 340 a day, 15 each and every hour. For 60 years. Don’t you think it might just be noticed by the authorities – even in the US?

The appropriate response to extraordinary claims is this:

Extraordinary claims require extraordinary evidence.

And

The claimant is required to supply the evidence.

SCAM meets neither of these requirements. In particular the fantastic claims of homoeopathy, ear candling, colonic irrigation, reflexology, iridology, therapeutic touch remain totally unproven. The basic claims of chiropractic and osteopathy remain unproven.

Of course medicine has made some fantastic claims in the past, and some of these have not held up under scrutiny so have been discarded. Other fantastic claims have been tested, often repeatedly, and have stood up to that scrutiny.

Let’s just consider one example.

The claim that a patient can be rendered unconscious by drugs, kept alive and insensible to the severe pain of a surgical operation, and then recovered to full consciousness remains a truly fantastic claim. But that is what medical anaesthesia is, and after 150 years continues to be, in spite of, or perhaps because of, the ongoing scrutiny this area of medicine is repeatedly subjected to.

This of course is an example of the inherent self criticism of medicine. Everything is up for comment, scrutiny and research.

Contrast this with SCAM, where there is no attempt to challenge the underlying claims on which it rests.

Pseudoscience.

By this I mean the misuse of scientific terminology and science itself, so characteristic of SCAM. For example the reference to the Uncertainty Principle I referred to earlier. This is also popular with the likes of Deepak Chopra, who uses the principles of quantum mechanics to describe human relationships and other aspects of his particular SCAM. Quantum physics is a theory about sub atomic particles, and the uncertainty principle refers to the spin or trajectory of such particles. Applying quantum mechanics in such an erroneous way is just one example of the pseudoscience of SCAM. There are plenty of others.

Commercialism.

The SCAM industry is large and growing. Proponents of SCAM use this commercial success as validation of SCAM, but it is not a valid argument – the Spice Girls were very popular but that does not validate their music. The Nazis were popular, so was eating whale meat.

Popularity does not of itself validate SCAM, and the huge commercial interests in SCAM are not of themselves proof of its efficacy.

Commercialism is a criticism often leveled at medicine by Quacks, particularly regarding the drug industry, but they are no longer immune from that criticism themselves. It is ironic that they use commercial success as validation of SCAM, but as an attack on medicine.

I was going to use the term fascism as my last Ism of SCAM, but it does conjure up emotional images that may not be appropriate. But I have not come up with a better term so

Fascism it is.

I do not mean that SCAM quacks go about rounding up people and executing them. Fascism in this context means the use of legal and political avenues to prevent your opponents from speaking out.

I appeared before the Select Committee on Government and Finance as it considered the Trans Tasman Therapeutic Goods Agreement. During my meeting with the Select Committee I was asked what I thought of homoeopathy. After trying to evade the question, as I thought it irrelevant, I told them exactly what I thought of homoeopathy. The response to my comments by the NZ Council of Homoeopathy was telling. I was attacked for being unprincipled and ignorant – i.e. attack the messenger and try and shut him up. This is a classic fascist tactic. Not infrequently in the past I have received veiled threats – not that’s inaccurate – they weren’t veiled at all – overt threats to sue me for libeling SCAMs. Steve Barrett, who founded the National Council Against Health Fraud, has been sued six times always unsuccessfully – he has successfully countersued twice. Such use of the law to silence their opponents is not infrequent and that is what I mean by fascism.

What we are facing is a loss of confidence in medicine. We are perhaps not meeting the needs of patients, but what are these unmet needs? I don’t know, but perhaps SCAM is filling a gap. Do we spend enough time with our patients? Have we lost our humanity and empathy? How many of us touch our patients – appropriately of course.

I believe much of the rise of SCAM reflects badly on us. And we should attend to such matters ourselves.

We can always improve our profession. But the failings of medicine are not of themselves a validation of SCAM.

There are many alternatives to medicine that no doubt provide comfort and succor to ill patients and to their families. Music, pleasant surroundings, fresh air, massage. Some patients derive great help from prayer or mediation or other religious practices. But these are not medicine or alternative medicine.

What do I think should be done about SCAM?

Perhaps surprisingly – not a lot.

Despite all my previous comments, I regard SCAMs and quacks as basically harmless.

But there are some exceptions to this. One area of great concern to me is opposition to vaccination. This is popular amongst many quacks and must be resisted and attacked. Even worse is the pedaling of alternative homoeopathic vaccines by some quacks. This is potentially dangerous, from an individual patient and from a public health point of view.

The opposition to vaccination reveals much about the potential dangers of accepting SCAM at face value, and not challenging it. The CDC in Atlanta voted vaccination as the health intervention with the most benefit for the least risk. Exciting new areas are opening with vaccination – for example the vaccine against strains of HPV that can cause cervical cancer – what a fantastic advance, and how disgraceful the opposition from those who say it will encourage early sexual encounters! Other vaccines on the horizon include one against malaria. This has the potential to help save millions of people from misery and early death. Where is SCAM’s involvement in such advances? Nowhere! Except opposition to vaccination.

Similarly opposition to public health measures such as fluoridation of water supplies or addition of iodine to salt or other foods must be resisted. Other potential dangers include the denial of medical care to children, and have we not seen some tragic cases of this in New Zealand. One thing that has fascinated, and appalled, me about such cases is that if Jehovah’s Witness parents refuse a necessary blood transfusion for a child, the courts will intervene promptly, as they should. But if parents refuse medical care on the grounds that they will instead use SCAM, the child’s doctors become the villains, and the press side with the parents and turn the whole matter into a media debate rather than a legal one.

Let’s be clear about this.

Children requiring medical care deserve the protection of the state and the authorities if their parents or guardians refuse to allow that care. We, the state, society and the medical profession, we all have a duty to intervene where patients cannot advocate for themselves, and let’s stop pussy footing around in the name of parents’ rights to access alternative care.

How should we as anaesthetists react if our own patients want to include some from of SCAM in their anaesthetic care? Well usually it is something harmless like that well known load of total bullshit called arnica. I don’t get too worried if patients wish to take it. But I absolutely refuse to administer such nostrums during an anaesthetic, as I have been asked to do. A small number of herbal medicines may be harmful peri-operatively, but so long as we are aware of these and take steps to avoid their use by operative patients, that is about as far as we need go.

So just in case I have not made myself quite clear about this, you may have been left with the impression that SCAM and quacks get right up my nose. Well what really gets up my nose is this.

We practice in a time when medicine has to more and more justify its position, provide appropriate evidence and admit mistakes and errors. I have no problem with any of this. That is how we should practice. We may not always get it right, but those are laudable goals for us to continually strive for. But at this time, when so much justification is required of medicine, we see SCAM and quacks being given essentially a free ride, by the media by politicians by the ministry and by the public and sadly by some of our own. And that is what really gets up my nose about SCAM in all is glorious variety of quacks and quackery.

The best form of defence is attack, but that should basically be with humour and education, not the courts and legislation.

However, I object to taxes being wasted on SCAM. If people want it they can pay for it.

Similarly I object to calls for us to engage with SCAM. This basically an invitation to dance in the theatre of the absurd, and we must resist it. I go further. I believe it is unethical to get involved with the fatuous nonsense spouted in the name of SCAM. We should oppose such moves loudly and frequently.

Education is I think the key here, but I despair at the scientific illiteracy displayed in much of the SCAM debate. The education system lacks the facility or ability to teach young people critical thinking or logic. I believe these should be core subjects at secondary school, along with science, mathematics, English, history, other languages, geography, art, physical education, music and so on. If we are to develop a knowledge based economy, surely we cannot do so in a climate of scientific, mathematical and literary illiteracy so common in the SCAM debate.

What we must do is answer the question I first posed.

What do you get if you cross a reflexologist and an iridologist?

Some one who diagnoses what’s wrong with your feet by looking at your eyes, and what’s wrong with your eyes by looking at your feet.

So we must speak up.

Our prostration in this debate is appalling. What are we so afraid of?

The saying “The only thing necessary for the triumph of evil, is the silence of good men” is often attributed to Edmund Burke.

If I can finish by slightly altering that aphorism:

“The only thing necessary for the triumph of alternative medicine is the silence of the medical profession”

Please take that as a challenge from me to all of you.