Bioethics falls for the "tell both sides" trope

I thought that a solid basic understanding of basic and clinical science was a prerequisite to be a bioethicist. AFter all, the prefix "bio" is in the word "bioethicist," which implies to me that bioethicists study the ethics of biology and medicine, which, of course, they do. Some bioethicists are even physicians. After all, to be able to study the ethics of a medical issue, it's rather necessary to understand just what the medical and scientific issues that cause the ethical issues and dilemmas being studied. Unfortunately, as I found out yesterday, it doesn't always work out that way.

After I wrote yesterday about CEASE therapy, which is basically homeopathy for autism, I didn't think I'd be discussing homeopathy again for a while. After all, homeopathy, being The One Quackery To Rule Them All, is the sort of thing that's highly entertaining and educational to discuss from time to time, because it is such concentrated woo, small doses are often more than enough, much as homeopaths claim that diluting remedies away beyond small doses into nonexistence makes them stronger. However, I guess this week circumstances force me to follow the Rule of Three and make this the last part of a trilogy of woo dealing with homeopathy. The reason, unfortunately, is because the journal Bioethics just published online in their "early view" section a bunch of articles discussing the ethics of homeopathy. Unfortunately, after a rip-rousing start that is purely science-based, the exchange degenerates from The Good to The Bad and then to The Ugly. So ugly does it get that the Time Cube guy of homeopathy, Lionel Milgrom, makes an appearance. Given that homeopathy is itself pretty much on par with the Time Cube when it comes to any grounding in science or reality, that's saying a lot.

It turns out that the battle started about two months ago, when someone named Kevin Smith of Abertay University wrote an article with about as simple and straightforwrd a title you could ever imagine about homeopathy: Against Homeopathy: A Utilitarian Perspective. In the article, Smith discusses the utter scientific bankruptcy of homeopathy and how from a strictly scientific view, homeopathy is completely untenable. None of this is new to anyone who's a regular reader of this blog or other skeptical medical blogs; so I won't cover his objections in great detail given that I share them and have discussed them in great length many times over the last seven years. For example, he blasts the Law of Similars and the Law of Infinitesimals, the twin pillars of woo that support homoepathy. I will, however, provide just a taste so that you can see that Smith knows what he's talking about:

I have argued above that homeopathy as a therapeutic system not only lacks plausibility, but runs counter to fundamental principles of science and rationality. Accordingly, it would be astonishing if clinical trials of homeopathy demonstrated any efficacy beyond placebo effects, and indeed to date the best clinical evidence has demonstrated no efficacy.11 Nevertheless, isolated reports of apparently successful treatments with homeopathy have been published. However, such reports may properly be accounted for by several factors, as follows.

Firstly, even amongst the highest quality clinical trials (of any forms of drug or intervention), occasional 'false positive' results occur, simply through chance statistical effects.12 Secondly, many clinical trials of homeopathy are rendered invalid by serious flaws, such as low subject numbers, poor design and slipshod execution. (In contrast with clinical trails of conventional medicines, homeopathic trials tend to be poorly funded and undertaken on a very limited scale.)13 Thirdly, papers reporting positive effects of homeopathy tend, for reasons of plausibility and quality, to be rejected by mainstream medical journals, appearing instead in, at best, low-ranking journals or, most frequently, in specialist 'alternative medicine' journals.14 Because the raison d'être of the latter type of journals is inextricably tied to a belief in 'alternatives' such as homeopathy, a self-referential situation occurs which is permissive to the acceptance of weak or flawed reports of homeopathic clinical effectiveness. Additionally, meta-analyses of multiple homeopathy papers are frequently flawed for similar reasons.

I couldn't have put it better myself, and, in all fairness, Bioethics deserves kudos for publishing such a paper. He even points out how extraordinary claims require extraordianry evidence and that homeopathy, going as it does against the known laws of science, requires extraordinary evidence to make us doubt those laws. He then discusses the claimed "benefits" of homeopathy and shows how they are not benefits at all, after which he then launches into the harm homeopathy does, including the risk of failing to seek effective science-based medical treatment, the waste of resources, demands to fund unscientific and ineffective remedies, and the weakening of support for science-based medicine. Ultimately, he concludes:

However, what can be stated at present with confidence is that for any CAM system that is as lacking in plausibility as is homeopathy, the foregoing utilitarian analysis must lead to the conclusion that the CAM modality in question ought to be rejected on ethical grounds.

All of which is quite true.

If only Bioethics had quite while it was ahead. But nooooo!. It had to publish several responses, and in doing so it embarrasses itself. Let's take a look at the responses that all hit the ether yesterday:

1. On the plausibility of homeopathic "similitude" by Paolo Bellavite
2. For homeopathy: A practicing physician's perspective by Richard Moskowitz
3. Homeopathy and extraordinary claims: A response to Smith's utilitarian argument by Irene Sebastian.
4. Is homeopathy really morally and ethically "unacceptable"? A critique of pure scientism by Lionel Milgrom

These turkeys lay so many eggs in these articles that there's now way even Orac, with his immense blogorrhea, could cover the all in a single blog post. Indeed, briefly I considered taking each of the and applying the not-so-Respectful Insolence that you know and you crave to each of them individually. However, that would force me to turn this entire week into homeopathy week. This week and part of next week, actually. That's too much homeopathy, even for this blog. More importantly, I'm not entirely sure that even Orac's supercomputing Tarial cell can withstand that concentrated an exposure to such utter pseudoscience for such a long period of time.

So let's take a look at each of them for some choice bits instead. Paolo Bellavite, for instance, tries to argue that Smith didn't understand the Law of Similars and was therefore oh-so-unfair when he castigated that aspect of homeopathy. Bellavite tries to do this by claiming that the Law of Similars is actually plausible. Seriously, that's what he argues. He seems particularly peeved at how Smith criticized the analogy homeopaths sometimes make between homeopathy and vaccination, something that richly deserves to be criticized, given that, unlike homeopathy, vaccines actually use easily measurable amounts of a substance and we have an understanding of how vaccines work. Here's Bellavite's argument:

Based on the systemic networks which play an important role in response to stress, a unitary and general model is designed: homeopathic medicines could interact with sensitive (primed) regulation systems through complex information, which simulates the disorders of natural disease. Reorganization of regulation systems, through a coherent response to the medicine, could pave the way to the healing of the cellular, tissue and neuro-immunoendocrine homeodynamics. Preliminary evidence is suggesting that even ultra-low doses and high-dilutions of drugs may incorporate structural or frequency information and interact with chaotic dynamics and physical electromagnetic levels of regulation. This model is backed by a large number of published studies from our laboratory and others, by toxicological evidence such as the emerging fields of hormesis (beneficial effects of low doses of toxic substances),3 of neuropharmacology,4 and of systems biology.

Now that's some mighty fine woo there. It's impressive-sounding gobbledygook, isin't it. Notice how, though, if you break it down, it means nothing. Seriously. What is a "primed regulatory system"? How could even a "primed regulatory system" interact with nonexistent molecules, given that most homeopathic remedies are diluted to the point where it's incredibly unlikely that even a single molecule remains. As for the evidence that homeopathic remedies transmit "complex information " to anything, well, there is none. "Chaotic dynamics" and "physical electromagnetic levels of regulation"? Well, that's just getting silly, and hormesis is not like homeopath, as much as homeopaths try to claim it for their own. And, of course, there's the all purpose invocation of systems biology. Maybe that's why near the end of his rebuttal Bellavite has the audacity to claim that homeopathy is at the "frontiers of science."

Next up is Richard Moskowitz, who takes the physician's perspective to argue that homeopathy works. In his article, he manages to Gish gallop every homeopathy apologetic I've seen. Tirade against big pharma? Check. Characterizing medicine as "forcing" something to happen? Check. Attacks on clinical trials as not bineg adequate to study homeopthy? Check. It's there too. Claims that homeopathy works in animals and in newborns, meaning it can't be placebo.

Of course.

He even claims that "many experiments" show that infinitesimally diluted substances have biological effects. Of course such studies have been deconstructed on this blog many times, and they show no such thing. Besides, no one denies that even very dilute chemicals can have effects. Homeopathy, however, goes way beyond that to the point where there is almost certainly not a single molecule left of the original substance in most homeopathic remedies. All of tis is summed up thusly:

But can a higher compliment be paid to a medicine than that its action cannot be distinguished from a gentle, spontaneous, and long-lasting cure requiring no further treatment? Doesn't the irony lie on the other side, that this optimal response is relegated to the placebo side of the equation, while drugs are valued only when they can overpower the physiology of as many patients for as long a time as possible? I'm glad that our cures remain on the placebo side of things, because until we develop more inclusive models of causality and the energy field of the patient as a whole, that is precisely where they belong.

Why yes. Yes they do belong "on the placebo side of things." but not in the way that Moskowitz thinks. He seems to think that being "on the placebo side of things" is a good thing.

Then there's Irene Sebastian. Her counterattack against Smith is as lame as an appeal to popularity. No, I'm serious. That's basically what it boils down to. Well, an appeal to popularity following appeals to the "memory of water." She quotes Luc Montagnier, who did indeed win a Nobel Prize but of late has come to suffer from what I like to call the Nobel Disease, in which a Nobel Laureate becomes a crank. Also there's the tired old excuse that randomized clinical trials can't test my woo:

Allopathic medicine is based on a deductive-nomothetic model. The fact that all patients are treated in the same way makes the double-blind, randomized, placebo-controlled trial an excellent method to test hypotheses based on this model. Homeopathic medicine is based on an inductive-idiographic model. In this model, individual expressions of the disease process, rather than being ignored or removed from the data, are of paramount importance. Given this model, provings are the most appropriate method to advance the science of homeopathy. While there are some situations in which RCTs may be useful for homeopathic research, the RCT is of very limited value in advancing the field of homeopathic medicine.

This is just making excuses, of course. We've heard this before, not just from homepaths, but from cranks and quacks of every stripe. But back to the argumentum ad populum. Did you know that you can't criticize homeopathy as unscientific and unethical without criticizing...Gandhi:

Hundreds of thousands of physicians prescribe homeopathic medicines. Given that most users of homeopathic medicines are in fact also proponents, a conservative estimate of the number of people Dr. Smith has labeled 'unethical' is 200 million. Mahatma Gandhi, one of the great moral visionaries of the 20th century and a strong proponent of homeopathic medicine, is also 'unethical' according to Dr. Smith's logic

Ah, yes. Hilarious, isn't it? Here's news for ya, Irene: I'm with Smith. Those hundreds of thousands of physicians who prescribe homeopathic medicines are either ignorant or unethical. Don't like it? You'll have to do better than that.

Last up is our old friend Lionel Milgrom. When I described Milgrom as the Time Cube guy of homeopathy, I was not exaggerating. He is the Master of All Homeopathic Woo. Just type his name into the search box of this blog if you don't believe me. I've written about him several times over the last few years. In fact, I might be due to write about him again because he's recently published an even more woo-tastic defense of homeopathy elsewhere within the last couple of months.

In this instance, he's whining about "scientism." Now, one thing you should know is that anyone who whines about "scientism" is almost certainly a crank. Is it 100%? No. But it's a damned good rule of thumb and with Milgrom it's way more than that:

More perplexing is Dr Smith's claim that homeopathy could weaken support for science-based medicine. Such fear is rooted not in science but in scientism,13 i.e. the unscientific belief that compared to other forms of knowledge, science is the absolute and only justifiable access to truth.

Taken to the extreme, scientism defaults to Internetfueled inquisitorial intolerance14 which, supported by certain academics, sections of the media, and (usually anonymous) blog sites, systematically vilifies anything considered 'unscientific', e.g. the campaign to undemocratically rid Britain's NHS of its homeopathy/CAM facilities.

Here's the problem. I don't know anyone who claims that science is the absolute and justifiable access to the truth. Do you? Lionel is constructing what is known as your basic straw man attack on science, only he calls it "scientism." The argument is not that science is the only way to determine the "truth"; rather the argument is that it's the best way we have at the moment. If Milgrom can come up with a demonstrably better way to approach reality and derive generalizable, useful, and predictive postulates describing how nature works than the scientific method, by all means he should propose it. That's not what he's about, though. Like many homeopaths, Milgrom doesn't like science and clinical trials because, when rigorously applied to homeopathy, they leave the inevitable conclusion that not only is homeopathy about as close to impossible as any pseudoscience can be (i.e., it can't work) but that it doesn't work. If homeopathy did work, people like Milgrom wouldn't have to make up increasingly silly explanations explaining how it allegedly works.

Now, in all fairness, maybe Bioethics didn't do so badly in a way in that it let Smith have the last word in the form of an article entitled simply Homeopathy Is Unscientific and Unethical in which he firmly puts the previous four homeopathy apologists in their place. Here's an example:

Several of the respondents, in their letters in this issue and also in other published works, posit various complex models and claimed scientific phenomena to try to explain how homeopathic preparations may exert biological effects. However, these proffered explanations amount merely to ad hoc attempts to manoeuvre around the central problem: namely that it would be incredible to suppose that absent molecules could exert any effects at all. The authors deploy complex scientific concepts and elaborate terminology, including 'systemic networks', 'complex information', 'neuro-immuno-endocrine homeodynamics', 'chaotic dynamics', 'energy field' and 'inductive-idiographic'; however, the posited hypotheses of homeopathic action have no scientific validity. I would assert that such use of authoritative-sounding concepts and terminology, with no underlying substance, represents a form of obfuscation and locates these homeopathic hypotheses firmly within the domain of pseudoscience.

Again, Orac couldn't have put it better himself.

The problem, of course, is that Bioethics fell for the journalistic trope of "telling both sides." I suppose that in most bioethics problems there are two sides to tell, but in considering the science (or, more appropriately, the lack of science) behind homeopathy, there is not. For homeopathy to be true, huge swaths of what we know about physics would have to be not just wrong, but spectacularly wrong. I'd suggest that if the editors of Bioethics want to look at homeopathy as an ethics problem, they should consider it the problem of using no treatment, given that homeopathic remedies are nothing more than water, water doesn't have memory, and all that hand-waving about "complex information" and "chaotic dynamics" is nothing more than a modern version of a softly whispered magic spell or incantation made to sound like science.