Respectful Insolence

Blogging on Peer-Reviewed ResearchA common refrain among practitioners and advocates of alternative medicine is that the reason randomized clinical trials frequently fail to find any objective evidence of clinical efficacy for their favorite woo is because, in essence, science is not the right tool to evaluate whether it works. In essence, they either appeal to other ways of knowing, invoke postmodernist nonsense claiming that science is just one way of knowing that is not any better than any other ways, or both. The most outrageously absurd example of postmodernist silliness in this regard that I’ve ever seen was the infamous “microfascist” paper, in which the authors called science “microfascism.” Less gleefully silly and over-the-top but peddling essentially the same message was an article claiming that double-blind randomized controlled trials of homeopathic medications are not ideally possible, and, it seems, every so often I come across alternative medicine silliness of this sort.

Today is one of those times.

This time around, it’s an article by one Christine A. Barry, from the School of Social Sciences and Law at Brunel University in the UK, who makes an argument I’ve never heard before, specifically that the best way to study alternative medicine interventions is not those nasty, cold, data-loving randomized clinical trials. Oh, no. Not humanistic enough. No, according to Dr. Barry, the appropriate methodology to study woo like homeopathy is anthropology, according to the abstract:

C. A. Barry, The role of evidence in alternative medicine: Contrasting biomedical and anthropological approaches. School of Social Sciences and Law, Brunel University, Gaskell Room 163, Uxbridge, Middlesex UB8 3PH, UK.

The growth of alternative medicine and its insurgence into the realms of the biomedical system raises a number of questions about the nature of evidence. Calls for ‘gold standard’ randomised controlled trial evidence, by both biomedical and political establishments, to legitimise the integration of alternative medicine into healthcare systems, can be interpreted as deeply political. In this paper, the supposed objectivity of scientific, biomedical forms of evidence is questioned through an illumination of the multiple rhetorics embedded in the evidence-based medicine phenomenon, both within biomedicine itself and in calls for its use to evaluate alternative therapeutic systems. Anthropological notions of evidence are constructed very differently from those of biomedical science, and offer a closer resonance with the philosophy of alternative medicine. Examples are given of the kinds of evidence produced by anthropologists researching alternative medicine. Ethnographic evidence of ‘what works’ in alternative medicine includes concepts such as transcendent, transformational experiences; changing lived-body experience; and the gaining of meaning. It is proposed that the promotion of differently constructed modes of evidence can be used to legitimise alternative medicine by widening the definition of what works in therapy, and offering a critique of what people feel is lacking from much of orthodox medical care.

In other words, if that pesky scientific method won’t show that alternative medicine has efficacy against disease or symptoms, then the answer is easy: Use a different method and “widen the definition of what works in therapy”! Ugh! I wonder who paid for this study.

Dr. Barry’s paper was quite long, 12 pages of two-column text, with only two small tables and no figures; so summarizing it is difficult. However, her thesis appears to include several main arguments (see below). But, first, for you to see where she is coming from, I can’t resist pulling this excerpt from near the beginning of the paper. You know it’s going to be a load of postmodernist crap from the very beginning:

I wish to problematise the call from within biomedicine for more evidence of alternative medicine’s effectiveness via the medium of the randomised clinical trial (RCT). This call originates in part from the motive of ensuring that alternative medicine ‘works’ before providing it in a publicly funded service. I will suggest, however, that this call is also, in part, political and relates to the agenda of controlling the threat posed by alternative medicine to the long-standing hegemony of biomedicine in the West. I also want to highlight possible omissions and biases inherent in the RCT method, not always visible to its supporters. RCTs usually omit the measurement of important elements of ‘what works’ in alternative medicine, which often acts in a different way to biomedical drugs. By presenting ethnographic evidence, I wish to show how evidence, when seen from the perspectives of the users and practitioners of alternative medicine, hinges on a very different notion of therapeutic efficacy.

My interest in this debate arises from my experience as a patient of both biomedicine and alternative medicine. I can contribute from an outsider perspective, neither being a biomedical nor an alternative practitioner, but also from an insider perspective of having experienced both as a user.

So she’s a fan of the woo. That’s OK; it doesn’t disqualify her from discussing the matter. However, her false dichotomy between “biomedical medicine” and “alternative medicine” (a dichotomy that I have said on numerous occasions is meaningless and shouldn’t exist) really grated on me, and, given her claims that alternative medicine “acts in a different way” than “biomedical medicine,” it was clear right away that she was going to lay down some classic altie arguments over why their woo shouldn’t be held to the same standards of evidence to which “biomedical” drugs are held. She starts by denigrating randomized clinical trial (RCT) evidence as a class (while disingenuously stating, “I do not wish to discredit the notion of the RCT,” as if her bad arguments were capable of doing any such thing, her accusations of “hubris” against advocates of EBM notwithstanding). The biggest postmodernist howler in this introductory section is this:

There is no such thing as The Evidence, just competing bodies of evidence.

Microfascist that I am, I felt my hand moving towards my microtruncheon and my micro-jackbooted foot twitching, ready to do some stomping of this postmodernist drivel–that is, after I successfully (barely!) resisted the urge to spew my drink all over my keyboard and monitor. And, boy, did I have reason! It turns out that Barry’s indictment of RCTs boils down to a whine full of straw men (Barry’s complaints in bold, my responses in italics):

  1. RCT methodology measures what is easily measurable ignoring subtle and complex effects. Not exactly. RCT methodology measures objectively measurable outcomes, so that we can actually figure out if the treatment being studied has any objective evidence that it does anything therapeutic. As for “subtle and complex effects,” that’s just woo-speak for complaining about EBM’s emphasis on measuring actual efficacy. In actuality, most objectively measurable outcomes are in fact complex. If the effects are subtle, to me that’s just another word for very weak and probably of minor consequence.
  2. RCTs pay little attention to the context or provider of treatments. Barry says this as if it were a bad thing. In actuality, this is not entirely true. For one thing, randomized trials are conducted mainly in academic medical centers; physicians are acutely aware that translation out into the community may not always be easy or straightforward.
  3. The placebo concept has powerful healing properties not fully acknowledged in RCT methodology. It’s hard not to point out right here that Barry appears to be admitting that any therapeutic effects “observed” due to alternative medicine are in actuality placebo effects. My retort, of course, would be: Why should insurers or taxpayers pay for placebos? In addition, there really is no good evidence that the placebo effect has any real therapeutic effect, except for symptomatology. No objective anti-tumor response has ever been attributed to the placebo effect, for example. No lifethreatening disease has been cured by the placebo effect.
  4. Funding for trials is patchy and biased towards products with pharmaceutical industry interests. Ah, yes, the old “Help! Help! Big pharma is repressing real cures!” trope. In any case, with the existence and rapid growth of the National Center for Complementary and Alternative Medicine here in the U.S. and Prince Charles’ support of woo in the U.K., more and more money is being made available.
  5. EBM can be seen as a political move to protect the medical professions’exclusive expertise in healthcare. No, EBM is a move to improve the way medicine is practiced by culling treatments that have no evidence of efficacy and keeping those that do. This doesn’t just apply to alternative medicine, by the way. Quite a few conventional medical treatments are being revealed to be less effective or even ineffective, and properly used EBM will eliminate them, along with the woo. Pharmaceutical companies are none too pleased when that happens to one of their products.
  6. EBM can be seen as benefiting hospital managers more than clinicians and arising from the growth of managerialism and audit culture. TRANSLATION: “Audit culture” = “accountability” and a desire to improve measurable outcomes, both of which are to be avoided at all costs in alternative medicine.
  7. Compliance with guidelines derived from evidence is low. So what? All this means is that “biomedical” medicine needs to do a better job in getting practitioners to follow EBM, not that we should use our lamentably low compliance with guidelines as an excuse to give up and let woo rule.
  8. Teaching of EBM to clinicians can be conceptualised as ritualised practice that does not impact on clinical practice. Once again, if EBM doesn’t have an adequate impact on clinical practice, the answer is to work harder to make it more relevant to practitioners, not to let woo in on equal terms with scientific medicine.
  9. Evidence may be in conflict with patients’ wishes in patient-centred medicine. When this happens, patients are free to seek out woo if they so desire. Ethically, however, because there is no good evidence to support the use of the vast majority of alternative medical modalities, we are under no obligation to use them and indeed an argument can be made that it would be unethical to recommend a course of treatment that is not supported by evidence. In fact, ethically we are obligated to offer only treatments for which we have evidence of efficacy. In addition, this obsessions alties have with the supposed evils of RCTs neglects that RCTs are not the only form of evidence. Indeed, EBM takes into account a variety of evidence, from nonrandomized trials to the gold standard double-blind RCT. It’s a strawman to imply that double-blind RCTs are all that is acceptable.
  10. RCTs come low down in the hierarchy of patients’ decision making factors. Possibly, but this is a non sequitur. If the range of options offered to patients all have RCTs giving different probabilities of efficacy, as long as the patient is informed and understands, he or she can choose whatever he wishes. And, of course, it is perfectly appropriate to take into account things like treatment difficulty and side effects. But it’s impossible for a patient to make an informed choice without hard data.

In contrast, to Barry, alternative medicine is so much better, as long as you redefine what “efficacy” means. Check out this additional howler, this time about homeopathy:

The nature of Homeopathy precludes the straightforward administration of clinical trials to measure it. Based on the principle of treating like with like, homeopathic remedies are developed from substances in the natural world. A picture of the symptoms of these substances is catalogued by ‘proving’ the effects on healthy volunteers. A muchdiluted form of the remedy is then administered to patients suffering with a picture of symptoms that is closest to that particular remedy. Each remedy picture includes multiple physical symptoms in multiple body locations, diverse psychological and emotional states, and aspects of behaviours that are not part of biomedical diagnoses. For example symptoms that improve on violent motion, particularly dancing (irrelevant to a biomedical diagnosis) is one of the keynote aspects of the symptom picture for Sepia (Vermeulen, 2000). Different individuals with the same biomedical diagnosis will be prescribed different remedies, as their symptom and personality picture will likely be different in each case. So two important aspects of homeopathy, individual prescribing and attention to non-biomedically recognised ‘symptoms’, problematise the use of RCT methodology.

RCTs carried out on alternative therapies necessarily entail reducing the complexity of the intervention to fit the reductionist nature of the RCT method. As a result, the therapeutic intervention as tested in RCTs is in most cases quite different to the interventions used by alternative practitioners in everyday clinic situations.

Moroever, apparently alternative medicine “works” if the patient believes it works:

Users of homeopathy did not see a need for scientific testing and were happy with their own judgement of whether the treatment was working for them. Any existence of RCT proof that the remedy was efficacious was never sought. The science of biomedicine was perceived as oldfashioned and rejected in favour of the quantum and chaos theories of modern physics. Several referred to Capra’s (1976) book on parallels between eastern mysticism and quantum physics as a rationale for favouring a more modern notion of scientific enquiry about healing. Interestingly, Verhoef (2004) showed in qualitative research with CAM patients, that RCTs came bottom of their hierarchy of evidence. Anecdotal evidence, particularly from friends and family, rated highest.

Of course, anectodal evidence is almost completely useless for determining efficacy, given the multiple biases, including confirmation bias, regression to the mean, and many others. What Barry considers “complexity,” I consider not having any idea what you’re doing, hiding behind “individualization” of medical treatments to each “unique” patient as a means of masking the lack of any evidence to support the efficacy of homeopathy or any scientific plausibility to suggest how or why it could possibly “work.” Moreover, I always know that I’m dealing with Grade A primo woo whenever I see any sort of appeal to quantum and chaos theories as a reason for why alternative medicine works, especially with the dismissal of “biomedicine” as quaint or old-fashioned. In reality, it’s alternative medicine that’s old-fashioned, given that the vast majority of it was envisaged long before we understood how the body actually worked or the scientific mechanisms of disease.

Barry goes on to argue that the very act of testing alternative medicine in RCTs irrevocably alters the nature of the treatment being study by “medicalizing it” and making it more like a “biomedical intervention and that the blinding procedure interferes with treatment. She seems to think this is insight. I call it bullshit.

So what is the answer? According to Barry, we need to study the efficacy of alternative medicine using anthropology:

Just as the scientific laboratory method and the nature of population statistics have shaped the nature of RCT evidence, so too anthropological method influences what constitutes evidence. Ethnographic research is conducted in everyday reallife settings and so can pay attention to the all-important contextual features of interaction.6 Reality is seen as ever-changing through a series of processes, formed by interactions and relationships between people, and always affected by the context in which social actions take place. The method utilises an observer situated in the context, not researching from afar. The focus of research is neither wholly predetermined nor tightly structured. This allows for research to uncover issues of importance to participants that may have been ignored in the literature. Shifting the focus to the perspective of the actors involved, and seeking the native point of view, not mirroring the prior concerns of the academic community, can produce powerful new interpretations.

She concludes:

Each of these pieces of ethnographic research contributes to a different notion of evidence in alternative medicine. Each produces a different answer to the question ‘Does it work?’ The work of anthropologists has come much closer to investigating the power of alternative medicine as it is viewed by those who use it. What ‘works’ for alternative medicine users and their therapists do not just include relief from physical symptoms. It also includes changes in beliefs about health, healing and disease; the gaining of meaning of illness experience in the context of the life story; bodily experiences and changed view of body-self; transcendent, transformational and spiritual healing experiences; changed identity; and a powerful dialectic relationship with the therapist. None of these aspects of therapeutic effectiveness is measured within existing clinical trial research. Whilst there are calls to include quality of life measures in RCT research more generally, such measures still do not incorporate any of the above.

In other words, inappropriately adapting a discipline (anthropology) to study something that it was not intended to study (whether a medical intervention has a therapeutic effect) will produce the result that alternative medical practitioners want: a “transformation” of alternative therapies found ineffective using scientific medical methods to one that is now magically “effective” because its users and the sociological group they are in believe that it works.

But that’s not the silliest part of the article. This is:

Such alternative evidence may prove useful in what David St. George, an NHS consultant, has called the potential for holistic transformation of the NHS through a synthesis of science and spirituality into a new paradigm. As he puts it ‘Perhaps alternative and complementary therapists can help the NHS to break out of its own prison’…Anthropological and other qualitative forms of evidence may prove a political tool to assist in this enterprise of transformation.

Ethnographic research in alternative medicine is coming to be used politically as a challenge to the hegemony of a scientific biomedical construction of evidence. The introduction of ethnographic forms of evidence that represent the grounded experience of users and therapists of alternative medicine communities act as a critique of biomedical notions of evidence. Thus anthropological evidence can be used to open a debate about what one should be measuring as evidence of alternative medicine efficacy, and whether one should be measuring it at all.

My guess is that alties would say we shouldn’t be measuring pesky things like objective outcomes at all, because that would reveal their favored form of woo to be ineffective, but that’s just the microfascist in me talking. Of course, the very premise of this conclusion is dubious at best, because I do not accept that a “holistic transformation” incorporating spirituality into a “new paradigm” is necessarily a good thing. In reality, it’s just an excuse to mingle woo with scientific medicine on supposedly equal terms. At least Barry is upfront about arguing that the purpose of advocating this shift to anthropological evidence is designed to support a political challenge to the “hegemony” of science, rather than an actual scientific argument. At least that’s something, and it allows those whose minds aren’t full of postmodern nonsense to recognize a crock when they see it.

Comments

  1. #1 Bronze Dog
    May 10, 2007

    …her claims that alternative medicine “acts in a different way” than “biomedical medicine,” it was clear right away that she was going to lay down some classic altie arguments over why their woo shouldn’t be held to the same standards of evidence to which “biomedical” drugs are held.

    I’m reminded of someone claiming that the Consumer Reports tests that showed failure for the Ionic Breeze didn’t apply because the Ionic Breeze worked in a different way than other air filters. Of course, doing something a different way doesn’t make up for the fact that the IB didn’t filter the air. I thought that’s what air filters did.

    You might as well claim that running along the ground, Freakazoid-style making wind noises is another method of flying and thus altimeters don’t apply.

  2. #2 Russell
    May 10, 2007

    Please tell me her doctorate is not in a science field.

  3. #3 Graculus
    May 10, 2007

    One thing the alties seem to fail to understand is that those quaint primitves (the myth of the State of Nature rides again!) whose herbs and treatments they are promoting used EBM (within context) to determine treatments.

    If they hadn’t been a practical folk, our species wouldn’t have made it this far.

  4. #4 Stuart Coleman
    May 10, 2007

    I hate to say this, but with these people, you’re fighting a losing battle. They’re convinced beyond all reason that their stupid little pet woo works, and, science be damned, they’ll never stop thinking that. Woo is like a parasite that kills the critical thinking part of the brain then spreads itself to other susceptible hosts. Very sad.

  5. #5 Justin Moretti
    May 10, 2007

    Amen, Graculus. I’ve got no problem with ‘vegie patch pharmacotherapeutics’, but homeopathy and its fellow travesties spit in the faces of all those generations of long-dead medicine men (and women) who watched in anguish as patient after patient died while they slowly, agonizingly, tried to build up an armamentarium of things that actually worked.

  6. #6 S. Rivlin
    May 10, 2007

    Just imagine an ethnographical (pharmaceutical industry workers) approach to the testing of new drugs that had failed RTC. Before you know it, doctors will prescribe antimigraine medicine for the treatment of hemorrhoids.

  7. #7 Jody
    May 10, 2007

    Microfascist that I am, I felt my hand moving towards my microtruncheon and my micro-jackbooted foot twitching…

    ROTFLMAO.

    May Cthulhu bless you by consuming you first.

  8. #8 TheProbe
    May 10, 2007

    “Before you know it, doctors will prescribe antimigraine medicine for the treatment of hemorrhoids.”

    Many of the Alties would benefit from this, considering where they keep their brains.

  9. #9 Randall Shane
    May 10, 2007

    What ‘works’ for alternative medicine users and their therapists do not just include relief from physical symptoms. It also includes changes in beliefs about health, healing and disease; the gaining of meaning of illness experience in the context of the life story; bodily experiences and changed view of body-self; transcendent, transformational and spiritual healing experiences; changed identity; and a powerful dialectic relationship with the therapist. None of these aspects of therapeutic effectiveness is measured within existing clinical trial research.

    In other words, her advocacy for alternative medicine boils down to this : it’s better to feel good about having disease rather than to actually cure it.

  10. #10 KeithB
    May 10, 2007

    Orac wrote:
    “EBM can be seen as a political move to protect the medical professions’exclusive expertise in healthcare. No, EBM is a move to improve the way medicine is practiced by culling treatments that have no evidence of efficacy and keeping those that do. This doesn’t just apply to alternative medicine, by the way. Quite a few conventional medical treatments are being revealed to be less effective or even ineffective, and properly used EBM will eliminate them, along with the woo. Pharmaceutical companies are none too pleased when that happens to one of their products. ”

    I talked to a Psychiatrist right after Nerontin was shown to be ineffective as a mood stabilizer. He basically said something like “I have seen it work in patients so I know the study is wrong.”

  11. #11 daedalus2u
    May 10, 2007

    Orac, I wish to correct the baseless aspersions you have cast upon the placebo effect. I have written quite an extensive blog on the placebo effect. The placebo effect is quite real, it is simply a technique to switch one’s physiology from the “fight or flight” state to the “rest and relaxation” state.

    Any technique that will do this will be an effective placebo. If you are already in the “rest and relaxation” state, then a placebo won’t do anything for you. However, if you are in the “fight or flight” state, and a placebo brings you out of it, the placebo can be a life-saving treatment, a placebo is not merely symptomatic relief.

    The physiology behind the placebo effect is reguluated by nitric oxide. Raising nitric oxide levels will tend to better invoke the “rest and relaxation” state and so will tend to produce a better state of health due to increased repair of cellular systems.

    As far as a placebo producing life saving effects? There is a treatment for myocardial ischemia due to end-stage coronary artery disease called Myocardial laser revascularization. Essentially this is blasting small holes in the heart with a laser with the idea that the hole will fill with blood and become a vessel that will carry blood. It turns out that the holes fill with scar tissue and so don’t carry blood, but patients do get “better” compared to no treatment (via instrumental measures). When compared against placebo treatments the laser patients do the same as the placebo treatments. Blasting holes partway through someone’s heart with a laser is an effective placebo.

    Since raising nitric oxide levels would invoke the placebo effect pharmacologically, and so should have have at least “placebo effectiveness” against essentially every disease. I suggest that might be a better “control” to use in a pharmacological trial.

    No doubt different placebos have different effectiveness, depending on which type of woo resonates with the victim’s chi, and or wallet. What we really want to determine in a RCT is whether the treatment is better than the “best” placebo (or actually better when combined with the best placebo).

  12. #12 sailor
    May 10, 2007

    “No objective anti-tumor response has ever been attributed to the placebo effect, for example. No lifethreatening disease has been cured by the placebo effect. ”
    This may be true especially when it comes to tumors which don’t seem to be too affected by stress. However in cases where recovery depends on the immune system functioning well, recovery could be blocked by anxiety which has been shown to adversly affect the immune system, so a plecebo, in as much as it reduces anxiety could aid real recovery, not just help with symptoms.

  13. #13 daedalus2u
    May 10, 2007

    What about warts, aren’t they sort of like a tumor? A virally induced tumor? Placebos have been shown to work on them.

  14. #14 Whatever
    May 10, 2007

    You might as well claim that running along the ground, Freakazoid-style making wind noises is another method of flying and thus altimeters don’t apply.

    I shot water through my nose, and all over my monitor when I read this.

    How come the alties who claim their woo can cure cancer aren’t doing just that? Seems to me if you could cure cancer it wouldn’t matter what the medical profession thought of you. You have people who were sick, and now they are cured. That’s real marketing, quit complaining about how the tests are unfair and just start curing people. Then you will never have to be criticized again. Duh!

  15. #15 Jonathan Dresner
    May 10, 2007

    In addition to being lousy medicine, it’s a complete abuse of anthropology as a discipline to conflate it with bio-prospecting or make it about “effectiveness.” Anthropology is a social science which is fantastic at studying social relationships, communities, systems of belief and culture. But that’s as far as it goes, and though anthropologists can tell you what plants a group uses and how and what they think of them, it’s a gross mischaracterization of any reasonable standard of evidence to suggest that it’s the same thing as medical evidence.

    It’s weird, because Anthropology, under the influence of post-structuralist/post-modernist criticism — it can indeed be productive, when taken in moderation — is extremely self-reflective about its epistemological limitations; this doctrinaire anti-scientific approach is bad anthropology.

  16. #16 Joe
    May 10, 2007

    Is the Placebo Powerless?– An Analysis of Clinical Trials Comparing Placebo with No Treatment

    http://content.nejm.org/cgi/content/full/344/21/1594
    Accessed December 31, 2006

    NEJM Volume 344:1594-1602 May 24, 2001 Number 21

    “Background Placebo treatments have been reported to help patients with many diseases, but the quality of the evidence supporting this finding has not been rigorously evaluated.

    “Conclusions We found little evidence in general that placebos had powerful clinical effects. Although placebos had no significant effects on objective or binary outcomes, they had possible small benefits in studies with continuous subjective outcomes and for the treatment of pain. Outside the setting of clinical trials, there is no justification for the use of placebos.”

  17. #17 Martin R
    May 10, 2007

    Aargh. Welcome to my world, Orac. It never ceases to amaze me that people like this are allowed to survive at universities. Such. A. Load. Of. Stinking. Manure. And it’s still very much alive in British and Scandy archaeology.

    I did some digging on Christine Barry. She completed a PhD in anthropology (surprise!) in 2003 at Brunel university’s Centre for the Study of Health & Illness. Her thesis was published in 2003: The body, health, and healing in alternative and integrated medicine : an ethnography of homeopathy in South London.

    In a 2002 anthro paper she described herself as follows:

    “Christine Barry has worked her way through the social science disciplines, holding degrees in geography and psychology and having worked on sociological academic research projects for 9 years. She has finally found a home in anthropology and is currently a PhD student in the Social Anthropology Department at Brunel University, conducting an ethnographic study of homeopathy and Tai Chi in the community and in the NHS in South London.”

  18. #18 daedalus2u
    May 10, 2007

    Here is a study using instrumental measures that demonstrated that placebos made nausea worse and nocebos (the same intert pill but with a negative expectation) made it better.

    http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?CMD=search&DB=pubmed

  19. #19 Interrobang
    May 10, 2007

    If she were just suggesting studying populations of woo-users and documenting how they think and feel about themselves, woo, illness, and their bodies, and how they define and use “evidence” within their discourse paradigm, she’d be doing really good work. She also has a point about politics and bias in RCTs, at least historically, or have all those accounts I’ve read about things like breast cancer drugs being tested on males (so they don’t have to account for female hormones *headdesk*) been lying to me?

    There is room for legitimate concern and work in both of those areas (although the latter would probably fall more under bioethics or research methodology theory than anthropology), but that doesn’t mean that “competing bodies of evidence,” where “evidence” is defined in multivalent ways with multiple levels of rigour and validity, are automatically equivalent.

  20. #20 Orac
    May 10, 2007

    If she were just suggesting studying populations of woo-users and documenting how they think and feel about themselves, woo, illness, and their bodies, and how they define and use “evidence” within their discourse paradigm, she’d be doing really good work.

    I don’t disagree. I have no problem with these sorts of studies. But what she proposes goes way beyond that; in essence, if you read the whole paper it’s clear that she’s much less concerned about hard evidence and essentially argues that, if the group using the treatment believes it works, that is good enough.

    As for your example of breast cancer drugs being tested in males, that’s not nearly as wacky as you make it out to be. For one thing, conceivably such testing could reveal unexpected effects that don’t depend on estrogen. More importantly, though, men do get breast cancer. It’s uncommon, but they do get it. Indeed, I’ve taken care of several over the years. Moreover, in men, if the tumor is estrogen receptor positive, the treatment is Tamoxifen, just like in women. Men do make some estrogen. It’s not a lot, but it’s enough that blocking it will produce a therapeutic effect in breast cancer. After all, Tamoxifen and newer estrogen-blocking drugs are also effective in postmenopausal women, and they don’t make much estrogen anymore.

  21. #21 Coin
    May 10, 2007

    Such alternative evidence may prove useful in what David St. George, an NHS consultant, has called the potential for holistic transformation of the NHS through a synthesis of science and spirituality into a new paradigm.

    Wow. I think this is the most telling sentence in the whole thing…

  22. #22 Nat
    May 10, 2007

    And the university is named after Isambard Kingdom Brunel?

    http://en.wikipedia.org/wiki/Isambard_Kingdom_Brunel

    To further Bronze Dog’s analogy I wonder if Brunel had just thought/believed really REALLY hard that his ships wouldn’t sink and kill people, his tunnels wouldn’t collapse and kill people and his bridges wouldn’t collapse and kill people that he wouldn’t have had to refer to all that pesky observable reality.

    All you’d have to do is state that you feel the bridge is OK and regardless of what really happens that’s a perfectly acceptable form of evidence?

  23. #23 angry doc
    May 10, 2007

    Will she stake her safety on this “new paradigm”?

    http://angrydr.blogspot.com/2006/06/new-paradigm-in-vehicular-safety.html

  24. #24 Eamon Knight
    May 10, 2007

    The monarchy having come up on a couple of other blogs I read today, I keep getting hit with the fact that the future head of state of my country goes in for this crap. I’m starting to go all republican (in the small-r, non-American sense).

    I’d like to ask people like Dr. Barry the following question:
    Asssume I’m sick or injured, and being offered several therapies (both “biomedical” and altie). I want to know: which one(s) will fix the problem? Failing that, then which one(s) will best mitigate the effects of my disorder, and allow me to choose the best trade-off of longevity vs. comfort and vigor?
    If you can’t answer that question with at least ballpark estimates, and show why, then STFU.

    Of course, her “ethnographic” method would probably note that I’m a middle-aged, middle-class white male, with a scientific-technological education, whose livelihood depends on maintenance of the current crypto-fascist technocratic hegemony, and therefore my resistance to alt-med modalities for myself is determined by my socio-political niche. (Or some similar po-mo bullshit).

  25. #25 Chayanov
    May 10, 2007

    “In other words, her advocacy for alternative medicine boils down to this : it’s better to feel good about having disease rather than to actually cure it.”

    Given that altie treatments like homeopathy and reiki don’t cure anything, this attitude rather makes sense.

  26. #26 Owen
    May 10, 2007

    “Ethnographic evidence of ‘what works’ in alternative medicine includes concepts such as … changing lived-body experience”
    By changing into a dead-body experience, maybe? Good grief.

  27. #27 Felix Kasza
    May 11, 2007

    Dear Orac,

    I fail to see why you spent any of your processing power on this. After all:

    > School of Social Sciences and Law

    Idiots and shysters, a match made in hell. “Social Sciences” is a contradiction in terms, and vain Derridaesque efforts to obscure monumental ignorance behind a fog bank of blather do not change that.

  28. #28 Paul Power
    May 11, 2007

    Is it impossible to do an RCT on homeopathy?

    One could take a group of patients of a homeopathist and, after a consultation, give half of them what was prescribed and half a placebo disguised as the presecibed treatment (e.g. water from a tap/faucet).
    If the practitioner is unaware of which of his patients are being given a placebo then all the patients get the same level of personal attention and care from the practitioner. If the two groups do not show different success rates then the alties would have nowhere to go.

  29. #29 Chris Noble
    May 11, 2007

    Hmmm, there’s a lot of ethnographic evidence for the efficacy of trepanation (and no RCT that I know of).

    Is Barry also a user of this modality?

  30. #30 bcpmoon
    May 11, 2007

    Re

    The placebo concept has powerful healing properties not fully acknowledged in RCT methodology.

    I think the correct answer to this is that RCTs fully acknowledge the placebo concept, in fact RCT were designed to take it into account in the first place. The sole reason for setting up a trial so that everybody in all arms of a study has the same impression/mindset/bias is exactly the placebo effect. RCTs are the only way to separate its effects. Is that so hard to understand?
    And regarding Big Bad Pharma and the RCT: I bet Pfizer would have loved to have Torcetrapib tested under the anthropological paradigm. But no, they scrapped billions instead. I wonder what altie company ever had similar cojones to do something like that.

  31. #31 MikeB
    May 11, 2007

    Frankly, I simply tuned out after reading the word(?)’problematise’…hopefully Ben Goldacre will give this study a good going-over tomorrow.

  32. #32 Calli Arcale
    May 11, 2007

    “All you’d have to do is state that you feel the bridge is OK and regardless of what really happens that’s a perfectly acceptable form of evidence?”

    This reminds me of the Monty Python skit about the guy (played by Michael Palin, IIRC) who put up apartment buildings with hypnosis. The catch was that it only worked as long as none of the inhabitants of the flats ever doubted the process. ;-)

  33. #33 argh
    May 11, 2007

    When I feel my blood pressure rising, I reassure myself by remembering how irrelevant these people are. It must be infuriating for her to be part of an underfunded, unimportant organization with no power. Her job consists of spouting verbal diarrhea that will have no impact and change nothing. To paraphrase the poster I saw floating around on the net:

    YOU: shut the hell up
    WE’LL: actually treat patients

    Ahh, I feel much better now.

  34. #34 HolfordWatch
    May 12, 2007

    “EBM can be seen as a political move to protect the medical professions’exclusive expertise in healthcare”

    Couldn’t it actually function as a way to challenge any ‘exclusive’ expertise? Patients could often be as up-to-date, or more so, than their Dr re. the evidence on treatments for any illesses they’re suffering. Articles assessing the efficacy of various treatments can be relatively accessible (at least compared to, say, attempts to ab/use quantum physics to explain why homeopathy ‘works’). When a GP enthusiastically suggested that I try homeopathy, I was able to say that I didn’t think it would work, and explain why…

    One query Orac – obviously, you’re quite free to discuss blog about what you want, when you want to. But any reason this came up now, though? It’s dated from 2005…

  35. #35 Orac
    May 12, 2007

    Because I only became aware of it a few days ago and felt like blogging about it because it was so ridiculous?

    Really, I don’t need a reason other than that–or even less. ;-)

  36. #36 HolfordWatch
    May 12, 2007

    “Really, I don’t need a reason other than that–or even less. ;-)”

    Sure – wouldn’t argue with that, was curious as to whether it had come up elsewhere etc.

    btw, you know there’s a fair few papers out there in a similar vein…

  37. #37 Cam
    May 13, 2007

    This criticism of EBM seems to derive, in part, from the fear that it turns medicine into a soulless activity as forumlaic as a Nora Roberts novel. There may be some merit to that – I’ve worked with some internists who’d treat every patient with a given condition identically regardless of their individual requirements – but good doctors combine EBM with clinical acumen and basic compassion, as was always intended.

    Of course, it also derives in part from the desire not to have your pet variety of bullshit debunked.

    I also followed the link to the “microfascists” article, and as a family medicine resident in Canada, I’m deeply humiliated that the Canadian Institutes for Health Research provided the funding for that disaster.

  38. #38 davidp
    May 13, 2007

    Hilarious.
    Homeopathy would have given meaning to my recent viral infection (I’m out of balance, rather than just copping some random virus).
    The right mushrooms would have given me a transcendant experience while ill (hallucinations)
    Alas, I missed out on treatments that ‘work’

    I liked “Evidence may be in conflict with patients’ wishes in patient-centred medicine.”
    Reality is in conflict with my personal wishes. Please change reality. Ah, that’s “The Secret”

  39. #39 Ardem
    May 15, 2007

    I broadly agree with you, but it should be pointed out that simply running a therapeutic claim through an RCT filter does not necessarily produce a reliable result. The selection and assessment criteria used in an RCT also have to be clear and scientifically sound. Unfortunately they are often not so. I see this problem every day in my dealings with peer-reviewed papers in a mainstream branch of med sci. And it drives me up the wall, because most simply see the label ‘RCT’ and don’t bother looking any further. I think the limits of RCTs should be recognised and openly conceded by clinicians and researchers.

    The following works touch on this issue.

    What’s Wrong with Doctors
    By Richard Horton

    How Doctors Think
    by Jerome Groopman
    Houghton Mifflin.

  40. #40 i like latin
    May 15, 2007

    Hmm… let me see…

    I don’t like your results because I believe it works. Could the anti-science folks please get a new tact besides arguments from incredulity. I’ll leave out the other pesky ones since this seems to be their numero uno smoking gun.