MD, PhD, FMedSci, FRSB, FRCP, FRCPEd

As I write these words, I am travelling back from a medical conference. The organisers had invited me to give a lecture which I concluded saying: “anyone in medicine not believing in evidence-based health care is in the wrong business”. This statement was meant to stimulate the discussion and provoke the audience who were perhaps just a little on the side of those who are not all that taken by science.

I may well have been right, because, in the coffee break, several doctors disputed my point; to paraphrase their arguments: “You don’t believe in the value of experience, you think that science is the way to know everything. But you are wrong! Philosophers and other people, who are a lot cleverer than you, tell us that science is not the way to real knowledge; and in some forms of medicine we have a wealth of experience which we cannot ignore. This is at least as important as scientific knowledge. Take TCM, for instance, thousands of years of tradition must mean something; in fact it tells us more than science will ever be able to. Qi-energy, for instance, is a concept based on experience, and science is useless at verifying it.”

I disagreed, of course. But I am afraid that I did not convince my colleagues. The appeal to tradition is amazingly powerful, so much so that even well-seasoned physicians fall for it. Yet it nevertheless is a fallacy, I am sure.

So what does experience tell us, how is it generated and why should it be unreliable?

On the level of the individual, experience emerges when a clinician makes similar observations several times in a row. This is so persuasive that few doctors are immune to the phenomenon. Let’s assume the experience is about acupuncture, more precisely about acupuncture for smoking cessation. The acupuncturist presumably has learnt during his training that his therapy works for that indication via stimulating the flow of Qi, and promptly tries it on several patients. Some of them come back for more and report that they find it easier to give up cigarettes after consulting him. This happens repeatedly, and our clinician forthwith is convinced – in fact, he knows – that acupuncture is effective for smoking cessation.

If we critically analyse this scenario, what does it tell us? It tells us very little of relevance, I am afraid. The scenario is entirely compatible with a whole host of explanations which have nothing to do with the effects of acupuncture per se:

  • Those patients who did not manage to stop smoking might not have returned. Only seeing his successes without his failures, the acupuncturist would have got the wrong end of the stick.
  • Human memory is selective such that the few patients who did come back and reported failure might easily get forgotten by the clinician. We all remember the good things and forget the disappointments, particularly if we are clinicians.
  • The placebo-effect might have played a dirty trick on the experience of our acupuncturist.
  • Some patients might have used nicotine patches that helped him to stop smoking without disclosing this fact to the acupuncturist who then, of course, attributed the benefit to his needling.
  • The acupuncturist – being a very kind and empathetic clinician – might have involuntarily induced some of his patients to show kindness in return and thus tell porkies about their smoking habits which would have created a false positive impression about the effectiveness of his treatment.
  • Being so empathetic, the acupuncturists would have provided lots of encouragement to stop smoking which, in some patients, might have been sufficient to kick the habit.

 

The long and short of all this is that our acupuncturist gradually got convinced by this interplay of factors that Qi exists and that acupuncture is an ineffective treatment. Hence forth he would bet his last shirt that he is right about this – after all, he has seen it with his own eyes, not just once but many times. And he will doubt anyone who shows him evidence that says otherwise. In fact, he is likely become very sceptical about scientific evidence in general – just like the doctors who talked to me after my lecture.

On a population level, such experience will be prevalent in not just one but most acupuncturists. Our clinician’s experience is certainly not unique; others will have made it too. In fact, as an acupuncturist, it is hard not to make it. Acupuncturists would have told everyone else about it, perhaps reported it on conferences or published it in articles or books. Experience of this nature is passed on from generation to generation, and soon someone will be able to demonstrate that acupuncture has been used ’effectively’ for smoking cessation since decades or centuries. The creation of a myth out of unreliable experience is thus complete.

Am I saying that experience of this nature is always and necessarily wrong or useless? No, I am not. It can be and often is correct. But, at the same time, it is frequently incorrect. It can serve as a valuable indicator but not more. Experience is not a tool for reliably informing us about the effectiveness of medical interventions. Experience based-medicine is an obsolete pseudo-medicine burdened with concepts that are counter-productive to optimal health care.

Philosophers and other people who are much cleverer than I am have been trying for some time to separate good from bad science and evidence from experience. Most recently, two philosophers, MASSIMO PIGLIUCCI and MAARTEN BOUDRY, commented specifically on this problem in relation to TCM. I leave you with some extensive quotes from what they wrote.

… pointing out that some traditional Chinese remedies (like drinking fresh turtle blood to alleviate cold symptoms) may in fact work, and therefore should not be dismissed as pseudoscience… risks confusing the possible effectiveness of folk remedies with the arbitrary theoretical-metaphysical baggage attached to it. There is no question that some folk remedies do work. The active ingredient of aspirin, for example, is derived from willow bark…

… claims about the existence of “Qi” energy, channeled through the human body by way of “meridians,” though, is a different matter. This sounds scientific, because it uses arcane jargon that gives the impression of articulating explanatory principles. But there is no way to test the existence of Qi and associated meridians, or to establish a viable research program based on those concepts, for the simple reason that talk of Qi and meridians only looks substantive, but it isn’t even in the ballpark of an empirically verifiable theory.

…the notion of Qi only mimics scientific notions such as enzyme actions on lipid compounds. This is a standard modus operandi of pseudoscience: it adopts the external trappings of science, but without the substance.

…The notion of Qi, again, is not really a theory in any meaningful sense of the word. It is just an evocative word to label a mysterious force of which we do not know and we are not told how to find out anything at all.

Still, one may reasonably object, what’s the harm in believing in Qi and related notions, if in fact the proposed remedies seem to help? Well, setting aside the obvious objections that the slaughtering of turtles might raise on ethical grounds, there are several issues to consider. To begin with, we can incorporate whatever serendipitous discoveries from folk medicine into modern scientific practice, as in the case of the willow bark turned aspirin. In this sense, there is no such thing as “alternative” medicine, there’s only stuff that works and stuff that doesn’t.

Second, if we are positing Qi and similar concepts, we are attempting to provide explanations for why some things work and others don’t. If these explanations are wrong, or unfounded as in the case of vacuous concepts like Qi, then we ought to correct or abandon them. Most importantly, pseudo-medical treatments often do not work, or are even positively harmful. If you take folk herbal “remedies,” for instance, while your body is fighting a serious infection, you may suffer severe, even fatal, consequences.

…Indulging in a bit of pseudoscience in some instances may be relatively innocuous, but the problem is that doing so lowers your defenses against more dangerous delusions that are based on similar confusions and fallacies. For instance, you may expose yourself and your loved ones to harm because your pseudoscientific proclivities lead you to accept notions that have been scientifically disproved, like the increasingly (and worryingly) popular idea that vaccines cause autism.

Philosophers nowadays recognize that there is no sharp line dividing sense from nonsense, and moreover that doctrines starting out in one camp may over time evolve into the other. For example, alchemy was a (somewhat) legitimate science in the times of Newton and Boyle, but it is now firmly pseudoscientific (movements in the opposite direction, from full-blown pseudoscience to genuine science, are notably rare)….

The borderlines between genuine science and pseudoscience may be fuzzy, but this should be even more of a call for careful distinctions, based on systematic facts and sound reasoning. To try a modicum of turtle blood here and a little aspirin there is not the hallmark of wisdom and even-mindedness. It is a dangerous gateway to superstition and irrationality

16 Responses to The blurred line between sense and nonsense

  • I read this yesterday in the NY Times and should mention that it was in rebuttal to a previous piece of nonsense by another philosopher (Stephen T. Asma) that trumpeted not only pseudoscience and TCM, but also the public slaughter of a turtle!

    While I was relieved to see such a well-presented rebuttal, I have to tell you that the comment section was filled with personal testimony and savage criticism of “BigPharma” and the “medical establishment”. Many anecdotes were presented and one was left wondering if these people had even read the column. I am also relieved to tell you that there were a good number of scathingly critical comments made to the Asma column–but they were in the minority.

    I am discouraged by the response of some of your colleagues at the conference. I am accustomed to this from friends who have little or no science training (a shame in itself), but it’s always more troubling to hear these tropes from MD’s and others with medical training.

    As to “tradiition”, people seem to pick and choose about that as well. I don’t know many (under 80) who still use a “traditional” telephone, or even send a “traditional” message. There are hundreds of such examples, and yet so many people have a deep need to indulge in any cockamamie “treatment” they deem as “traditional” (even though it has been shown that acupuncture in its present form is anything but).

    Thank you for sharing this article with a wider audience.

  • To say that there is no way to test the existence of Qi is complete Bull Shit, basically you do not want to test it, it would destroy all your beliefs. There are dozens of ways to set up controlled experiments to verify what we can do if anyone actually wanted to test it rather than critically demolish
    When I was training as a Shiatsu Practitioner one of our many energy development exercises was to arrange 6 students backs turned at one end of the room and for 6 more students to project pulling or pushing energy. Unanimously we all affected the recipients, some being nearly knocked off their feet. Exchanging places, the same happened. Project push was push, projected pull was pull in every case. That’s a one in 64 chance of random chance. Doubled by exchanging places. As an exercise it was used repeatedly because it works. If used sucessfully on 3 occasions that’s a one in a million chance of happening randomly. But that is our experience so you will rubbish it. I challenge you to use it as indicator of something that should be investigated

    If only…..
    If only someone like you with your experience (sorry dirty word) and critical faculty would work with those that can work with Qi to design an experiment to the satisfaction of the scientific community, the world and medicine would be transformed beyond belief
    What I can do with energy beggars belief. If I made it public I would be locked up or worse. I have a track record of 96% success rate of radically changing the lives of of clients on antidepressants in 3 treatments or less, and to the best of my knowledge with permanent change. That’s cheaper quicker and more effective than the average annual cost of antidepressants, and safe on children too
    20 years ago you were on the road to Damascus and you saw the light, it is way past time for you to get on that road again. Maybe your work was axed because you had nothing positive to contribute and you didn’t actually research complementary medicines – please stop slagging us off as alternative

    Evidence based healthcare???? Can’t get TS3 measured on NHS in local labs despite it being the critical thyroid hormone, despite loads of evidence that it should be – why? because it is too expensive to test and in many cases TSH and T4 are sufficient, sod the rest of us. If you used your critical expertise in examining so called evidence based healthcare you really would get crucified

    I estimate a 90% chance that you will axe this comment, prove me wrong

    • your ability to predict chances seem to be on the same par as your understanding of science.
      this is what your websites tell me: “In addition to the more common conditions treated, I have also helped people with ME, MS, candida, terminal and post-operative cancer, and frozen shoulders….” and you profess to treat the following conditions: “•Anger Management
      •Anxiety and Stress
      •Arthritis
      •Back pain
      •Bipolar disorder
      •Breathing/respiratory problems
      •Cancer
      •Confidence issues
      •Depression
      •Digestive Disorders
      •Eating Disorders
      •Eczema
      •Emotional Issues
      •Fears and Phobias
      •Headache
      •Indigestion
      •Infertility
      •Insomnia
      •Irritable bowel syndrome (IBS)
      •Joint Pain
      •Low energy/Lethargy
      •Low Self-Esteem
      •ME/Chronic Fatigue Syndrome
      •Migraine
      •Muscular Tension
      •Nausea and sickness
      •Nightmares
      •Obesity
      •Pain
      •Panic Attacks
      •Sciatica
      •Sexual problems
      •Sinus problems
      •Skin conditions
      •Sleeping problems
      •Social anxiety disorder
      •Spiritual Issues
      •Stiffness/Tension
      •Weight problems”
      …and there is more:
      “You don’t have to be ill to enjoy Shiatsu, many people enjoy it simply because it is deeply relaxing. Shiatsu is a complementary therapy – it is not a replacement for western medicine. Shiatsu may help you with almost any medical condition. Experience has shown Shiatsu is effective for headaches, migraine, tension, neck, shoulder and back pain, sciatica, IBS, digestive disorders, respiratory, circulatory and uro-genital disorders, insomnia, PMT and menstrual problems. Shiatsu can be very effective for stress, anxiety, depression, fatigue, and grief. Shiatsu helps maintain health and is also used as a preventive measure.”

      maybe you are right? maybe you should be locked up?

    • If only…..
      If only someone like you with your experience (sorry dirty word) and critical faculty would work with those that can work with Qi to design an experiment to the satisfaction of the scientific community, the world and medicine would be transformed beyond belief

      There is one million dollars sitting and waiting for you Clive!
      Contact James Randi and set up the experiment with him. They will make sure it is designed to the satisfaction of the scientific community.
      He has great experience with such tasks (the fun part starts at about 30 mins but by all means watch the whole thing): http://youtu.be/iUt15WbF1_4

      We are all very excited to congratulate you when you have at last transformed our world beyond our belief and won a million dollars on top of that.

    • @Clive Barker

      Is that the same ‘energy’ that martial arts practitioners claim to be able to manipulate to fight off their opponents? Is so, you might find this video and this video interesting.

      If your ‘energy’ isn’t this bogus nonsense, then it would be great of you could take the million dollar challenge.

    • Please do the chi push/pull experiment under controlled conditions and revolutionise science and healthcare. It should be a piece of cake if it’s as reproducible as you report. In fact it would be a crime not to disseminate your remarkable findings.

  • Oh dear, and now you have made it public, on your web site and here and at your practice. Have you been locked up yet?

    Since all that you claim can apparently be so easily proved, why haven’t you done so yet?

  • To provide a slightly more moderate perspective, as an acupuncturist I don’t view Qi as a ‘real’ substance that can be pinned down and observed scientifically. To the best of my knowledge, although the Classical texts of Chinese medicine talk about an organising structure of channels, and the nuanced concept of Qi, it is a gross oversimplification – and in fact a misinterpretation – to talk about it as a discrete ‘energy’ that flows through invisible tubes, or something that is ‘projected’ from one person to another. To say it does or doesn’t exist is to miss the point, as it is simply an attempt to understand the cycles and patterns of nature. Applying it to medicine, what might be called ‘channel Qi’ no doubt encompasses nerve impulses, blood flow, fascial connections, the lymphatic system etc etc. Then there is the patient’s ’emotional Qi’ (Shen), the impacts of ‘environmental Qi’ (Wind, Heat, Damp etc), ‘constitutional Qi’ (Jing) etc, each of which have infinite sub-categories and interactions. Yes, a good GP might consider emotional and environmental factors before prescribing medicine or giving advice, but Chinese medicine has studied these influences and their manifestations in great detail for a very long time, and although there is a lot of nonsense and misunderstanding surrounding the subject, to think that science has already sorted the wheat from the chaff and that there is nothing to learn from this paradigm is staggeringly arrogant in my opinion.

    • PARADIGM? are you sure you know the meaning of the word?

      • ‘A set of assumptions, concepts, values, and practices that constitutes a way of viewing reality for the community that shares them’. That’s exactly what I meant – i.e. the concept of Qi is born from the Classical Chinese paradigm, as opposed to that of modern Western medicine. I don’t understand your objection to my use of the word.

        • ‘a framework containing the basic assumptions, ways of thinking, and methodology that are commonly accepted by members of a scientific community’
          I don’t think that the notions of TCM are commonly accepted by members of the scientific community. a new paradigm as you suggest is only needed, once the known facts are no longer explicable with the commonly accepted one. I fail to see that this is the case.

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