neglect
“Popularity takes the place of plausibility, tradition replaces validity, and individual experience is positioned above objective efficacy.”
This sentence (my translaation of the German original) comes from a book by Udo Endruscheit that I have been reading. It is entitled “Vom Zweifel zur Haltung: Eine Reise durch die Geschichte der Erkenntnis” (From Doubt to Conviction: A Journey Through the History of Knowledge) and outlines the epistemological development of truth from the early thinkers of antiquity to the postmodern voices of today. It traces how the concept of truth has changed, how it has been criticized, relativized, and deconstructed, and how these changes have shaped us and our thinking.
The statement was no necessarily meant to me applied to medicine, but it does aply capture a recurring epistemological pattern within large segments of so-called alternative medicine (SCAM). It describes a shift away from the truth towards criteria that are socially and psychologically compelling but scientifically nonsensical.
The substitution of popularity for plausibility is evident in the way many SCAMs have gained traction. Treatments such as homeopathy, naturopathic detox regimens, or paranormal energy-based healing have achieved global followings despite the fact that there can hardly be a mechanism of action that does not fly in the face of science. Their popularity is often driven by anecdotal endorsements, celebrity advocacy, and market forces rather than by convergence of experimental and theoretical support. Opinion counts more than truth, and the absence of plausibility in a SCAM is frequent and frequently ignored.
The elevation of tradition over validity is a defining feature of most SCAMs. Historical longevity is often presented as implicit evidence of effectiveness. “It would not have survived, if it were ineffective!” Yet, from a scientific perspective, tradition is a most unreliable indicator: ineffective or even harmful practices can persist for centuries in the absence of effectiveness and even safety. Bloodletting in pre-modern Western medicine offers a cautionary example. The critical issue is not whether a therapy is old, but whether it has been subjected to rigorous evaluation and shown to produce reproducible benefits that exceed placebo and other non-specific effects.
The dominance of individual experience over objective effectiveness is perhaps the most pervasive and psychologically persuasive cause of SCAM’s popularity. Patients’ testimonials, often sincere and seemingly compelling, are being touted as sufficient evidence of effectiveness. Yet individual experience is highly susceptible to regression to the mean, natural disease fluctuation, placebo effects, confirmation and other biases and confounders. Without proper comparisons, it is impossible to distinguish specific therapeutic effects from non-specific ones. Evidence-based medicine does not dismiss patient experience; rather, it contextualizes it with external evidence to avoid misleading us all.
The above statement by Udo Endruscheit was meant as a general characterisation of the way we currently handle and mishandle truth. As such it applies to much more than just SCAM. Yet, it also provides an apt critique of dominant tendencies within SCAM. Popularity, tradition, and personal experience are, of course, not inherently without value, but when they displace plausibility, validity, and objective effectiveness, they create a situation that is wide open to error, exploitation and often also harm.
In a nutshell: the truth matters; watering it down – as we all currently tend to do – carries serious risks in medicine as much as in life.
PS
I almost forgot!
Yes, I do recommend reading Udo’s most fascinating book.
The Nazi relic of the German Heilpraktiker – alternative health practitioner, who practise so-called alternative medicine (SCAM)) – is a topic that I wrote about repeatedly, e.g.:
- Prison sentence for a German HEILPRAKTIKER who issued false vaccination certificates
- Another death caused by a ‘Heilpraktiker’, non-medically trained alternative practitioner?
- A German Heilpraktiker was sent to jail for fraud
The path to becoming a Heilpraktiker is as unique as it is scandelously unregulated. By law, the profession requires no mandatory curriculum, no accredited school attendance, and no state-regulated university degree. Technically, anyone over the age of 25 holding a basic middle-school education (Hauptschulabschluss) can sit for the exam (the Heilpraktikerüberprüfung), even without any education or training at all. While some candidates choose to prepare by voluntarily attending a private and expensive school (a Heilpraktikerschule) for one to three years, the lack of standardized educational oversight leaves massive gaps in crucial medical and professional subjects.
Chief among these neglected subjects is, in my view, medical ethics. For those who do attend a school, average ethics instruction ranges from minimal to non-existent. Because private institutes design their own proprietary curricula, ethics is rarely taught as a standalone subject. Instead, it is briefly touched within broader modules concerning Berufs- und Gesetzeskunde (Professional and Legal Studies).
This systemic omission is directly tied to the narrow scope of the state licensing exam. Conducted by local health departments (Gesundheitsamt), the examination is explicitly designed around Gefahrenabwehr, i.e. the prevention of immediate danger to public health. The state’s priority is ensuring that applicants know what they are legally forbidden to do, such as managing highly infectious diseases, prescribing prescription-only medications, or practicing dentistry.
Consequently, broader ethical education is completely sidelined. Vital topics like the biomedical principles of patient autonomy, managing clinical conflicts of interest, and the complexities of informed consent are virtually absent. While some voluntary professional associations have established a code of conduct (Berufsordnung für Heilpraktiker), learning and understanding these ethical guidelines is entirely voluntary and self-guided.
Beyond ethics, maany other critical subjects are severely neglected in the Heilpraktiker schools, e.g.:
- Evidence-Based Medicine (EBM) and Scientific Literacy: students are rarely taught how to critically appraise clinical research, differentiate between correlation and causation, or recognize the cognitive biases inherent in anecdotal “success stories.”
- Pharmacology and Interaction Risks: While forbidden from prescribing prescription drugs, practitioners heavily utilize herbs and other dietary supplements. The study of how these substances interact with each other and a patient’s conventional pharmaceutical regimens is usually overlooked.
- Emergency Medicine and Differential Diagnosis: Because training lacks mandatory, standardized clinical rotations, practical competency in identifying red flags, such as atypical cardiac symptoms or early-stage oncological presentations, is dangerously variable.
The Heilpraktiker system offers unparalleled freedom of practice. At the same time, there is a near total lack of rigorous educational standards. This huge and dangerous imbalance leaves practitioners ill-equipped and put the public at unacceptable risks. Here are some examples of what can thus happen:
- The Klaus Ross / 3-Bromopyruvat (3-BP) Tragedy (2016): In one of Germany’s most notorious SCAM scandals, a Heilpraktiker operating a “Biological Cancer Center” in Brüggen treated terminally ill cancer patients with 3-Bromopyruvat, an unapproved, highly experimental chemical compound. Using an inaccurate kitchen scale to mix the powder himself, he administered massive overdoses via intravenous infusions. At least three patients died within days of the treatment, leading to his conviction for negligent homicide.
- The “BG-Mun” Fake Cancer Cure Scandal (Schrobenhausen): A Heilpraktiker, working alongside a businessman, defrauded desperately ill cancer patients by selling a fake “miracle serum” called BG-Mun for up to €5,900 per package. The practitioner explicitly pressured patients to abandon their conventional oncological treatments (like chemotherapy), promising that the serum would reverse tumor growth. Chemical testing later revealed the expensive liquid was nothing but worthless dilutions of glucose and basic amino acids. Multiple patients, including a 52-year-old esophagus cancer patient who went public with the story, died after their cancers metastasized following their cessation of proper medical care.
- Severe Complications from Autologous Blood Therapy (Eigenbluttherapie): A widespread SCAM among Heilpraktiker involves drawing a patient’s blood, mixing it with ozone, oxygen, or homeopathic remedies, and reinjecting it back into the muscle or vein to “stimulate the immune system.” Due to insufficient training in strict clinical hygiene, numerous documented cases have occurred where patients suffered from sepsis, internal abscesses, and systemic bacterial infections requiring emergency ICU hospitalizations.
- Misdiagnosis of Life-Threatening Emergencies: Because the Heilpraktiker exam does not mandate clinical training, practitioners have no clinical experience and frequently miss time-critical medical diagnoses. Documented cases include patients presenting with atypical chest pain being treated with acupuncture for “energy blockages” rather than being immediately referred to a hospital for an evolving myocardial infarction. Similarly, early-stage, highly curable melanomas or other malignancies have been misidentified as benign skin lesions or metabolic imbalances, delaying life-saving surgeries until the diseases reached terminal stages.
- Ineffective SCAMs for Acute Psychiatric Crises: Some Heilpraktiker choose to specialize in psychotherapy (Heilpraktiker für Psychotherapie). Scandals have arisen where patients suffering from severe clinical depression or acute psychotic episodes were treated solely with Bach flower remedies, St. John’s wort, or talking therapy rooted in esoteric ideas. The rejection of conventional psychiatric intervention and pharmaceutical stabilization in these acute phases has directly led to preventable self-harm and suicides.
So, why does Germany put up with the Heilpraktiker?
Despite repeated and fierce criticism, the German Heilpraktiker is sustained by a combination of law, politics, and tradition. The primary legal shield is Article 12 of the German Basic Law, which guarantees freedom of occupation (Berufsfreiheit). Because the state’s entry exam pretends to screen for immediate public danger (Gefahrenabwehr), courts pretend the system is legally sufficient; completely banning the profession would trigger severe constitutional challenges.
Furthermore, as often discussed on this blog, SCAM enjoys immense public popularity in Germany. Millions of Germans value the Heilpraktiker for the long and empathetic consultations that the overburdened conventional insurance system rarely permits. This widespread voter support, coupled with a highly organised political lobby, makes outright abolition a political non-starter.
Thus Germany continues to have a two-tier health system. This paradox exposes a profound cultural contradiction in the German psyche, which is famously stereotyped as risk-averse, highly bureaucratized, and obsessed with systemic order. While Germany tends to regulate everything from highway speeds to the exact composition of its beer, its tolerance of the Heilpraktiker system represents a massive, hazardous blind spot.
By clinging to an outdated Nazi-law out of political convenience and romanticized cultural traditions, the state has allowed this two-tier medical landscape to persist – one built on rigorous science, and another shielded by a legal loophole. In trying to uphold the constitutional freedom of occupation, the German legislative framework inadvertently compromises a far more fundamental duty: the protection of the public from dangerous quacks. This leaves a nation known for “playing it safe” in the ironic position of legally sanctioning pseudo-scientific nonsense within its healthcare system.
A fuller analysis of the Heilpraktiker can be found in my book “Vorsicht Heilpraktiker” [in German].
I was reminded of a paper that I published a long time ago – 23 years to be precise. It is entitled THE LECTURE FROM HELL. As it is not available online, let me give you a slightly revised version of it here:
When it comes to giving lectures, I have certainly made every mistake there is, and therefore I consider myself qualified to write this personal account on how to deliver THE LECTURE FROM HELL. I do this in the hope that others might learn from my imperfections.
In preparing for a lecture, it is best to be cool and leave things to the last minute. You are so gifted and competent that a few scribbles made on the way to the venue will easily suffice for fascinating your audience. Don’t bother enquiring who they are; what you have to say will capture the attention of a lay audience as much as that of a highly specialised one.
The kind people who have invited you will certainly have suggested a topic. Don’t get irritated by that; you know best what you can and want to talk about and, after all, it is always best to stick to what you know. If your subject is palliative cancer care, for instance, it should not be too difficult, after a few introductory sentences, to shift the attention to the most revealing survey you conducted on 10 back pain patients 25 years ago – cancer patients suffer from back pain too!
From the outset, you need to show the audience that you are better than they are. A good way of achieving this aim is to display your knowledge of as many acronyms as possible. Making abundant use of abbreviations has the added advantage that it could hide a few glitches in your arguments (or spelling). People might even think you are talking about palliative care after all.
Another golden rule is never produce evidence for your statements. Some people use visual aids to produce the evidence, but this is both tiring and confusing (and it would, of course, require much more preparation than you allowed for). If you want to use visual aids, use photographs of your kids (pets if you are childless) or your last holiday in Corfu. This will add the personal touch that people crave. Surely, if they had wanted evidence they would have gone to a library, not to your lecture.
It is advisable to spend as much time as possible with lengthy preliminaries, particularly if you are not really covering the subject as printed in the programme. Mention that you first met Cathy (who just introduced you) when you were both in nursery and give a full and colourful account of your relationship since then. If you haven’t actually been to nursery with Cathy, perhaps you could talk about the car accident you saw en route and what it made you think of. Or you could take the holistic approach, ask everyone to stand up, do a few relaxation exercises and feel the flow of energy in the body, room or universe. The obvious aim is to leave as little time as possible for the proper lecture. Thus, you can pretend to know much more about your subject than you had time to disclose and you can end your unfinished lecture with the upbeat exclamation ‘‘yeah! perhaps another time’’.
Most lecturers find the ensuing discussion period the most challenging part of their task. Not you! First, you have wisely ensured that there is no time left. Thus, the discussion slot will either be completely cancelled or it will be refreshingly brief. When the first difficult question comes your way, remember the important principle: you are so much cleverer than anyone else in this room! Make sure you show it. Arrogance has always been a perfect shield for hiding incompetence.
Another good strategy is to ridicule the person who dared ask the awkward question. Thus, they end up with egg on their face instead of you. If all else fails and you really don’t know how to answer, the best approach is to say: ‘‘this is a bit too complex right now; perhaps I could explain this to you later over coffee’’. Just ensure that you are safely on the way home when the coffee break starts.
Generally speaking, the overriding principles of a truly diabolically bad talk are quite simple. Lectures are neither the time nor place for transmitting knowledge to those who came to listen. Their predominant purpose is to massage the lecturer’s ego and increase their income. If you keep this in mind, you will stop worrying about things like evidence, structure and delivery and simply enjoy the outing.
I was reminded of this article because I saw the title of a recently published paper: HOW TO GIVE A BAD TALK. It starts as follows: “It is crucial to know how to communicate your work by delivering an effective talk, but our training for doing so is limited, so it is a skill often learned by watching others — who sometimes do it badly”.
Sadly, I could not read on; the journal asked almost 30 Euros for the privilege! So, I will never know what else I can do to give a truly poor lecture. Yet, I did learn something important: the knowledge of how to give a bad talk does not always come cheap!
I spent the last 2 months in France where it happened to be hot. Too hot for my taste! I could not do much during the day and, at night, I was unable to sleep well. As the heatwave carried on, it began to impact on my mood and health. I may be particularly sensitive to heat, but I am by no means the only one who suffered. Record-breaking temperatures and unprecedented ocean warming have triggered a global health emergency. Driven by climate change, modern heatwaves are predicted to strike with greater frequency, intensity, and duration, pushing human physiology to (and sometimes past) its limits.
Extreme heat operates as a silent killer by severely exacerbating pre-existing cardiovascular and respiratory conditions. It can also cause acute medical issues like severe dehydration, kidney damage, heatstroke, and even death. Extreme heat disproportionately impacts highly vulnerable groups, including older adults, children, outdoor laborers, and individuals who are unhealthy to start with. Urban populations face magnified dangers due to the urban heat island effect, which traps dense pockets of heat in city environments.
The consequences are already devastating. The recent heatwaves in Europe caused over 1,300 excess deaths within just a few weeks. Extreme heat contributes to a global toll of hundreds of thousands of heat-related fatalities each year. It also ripples through societal infrastructure. Extreme heat heavily strains our healthcare systems, disrupts local economies, worsens food and water insecurity worldwide, endangers local transport and other infrastructure. Here in France, for instance, we had prolonged cuts first of electricity and then on the Internet/telephone; many people and shops had to throw away the content of their fridges and freezers. Even more alarming: one of France’s largest rivers, the Loire, went completely dry.
An analysis of nearly 2,500 UK media articles covering the June heatwave found that most reports failed to connect the event to climate change, despite strong scientific evidence that global heating intensifies extreme weather. Approximately three-quarters of the articles made no reference to climate change or global warming, highlighting a significant gap between scientific consensus and public communication. Such omissions are problematic because they leave audiences without crucial context. Attribution science now allows researchers to quantify how much more likely or intense specific heatwaves have become due to greenhouse gas emissions, primarily from fossil fuel use. Without this information, heatwaves may be perceived as isolated or purely natural events rather than manifestations of a broader, human-driven trend. Failing to link extreme weather to climate change undermines public understanding and may weaken support for mitigation and adaptation policies.
The most worrying thing is that we are rapidly approaching irreversible thresholds. To mitigate this mounting catastrophe, immediate international cooperation is required. We must deploy both short-term adaptation strategies, such as robust local heat action plans and early warning weather networks, as well as aggressive, long-term global emissions reductions. And we also should vote out politicians who still:
- pretend that climate change is a hoax,
- blame their neighouring country, despite being huge polluters themselves,
- shout “drill baby, drill”,
- pretend that summers have always been hot,
- claim (against all medical knowledge) that humans will somehow manage to adapt to extreme heat.
Without urgent measures, the human and economic toll will escalate uncontrollably.
The Medical Journalists’ Association (MJA) has outlined six practical tips to help scrutinise health claims responsibly and accurately. They are primarily meant for journalists but, I think, they are also usefull for the general public, particularly when dealing with health claims in the realm of so-called alternative medicine (SCAM):
Check the source
Assess whether the claim originates from credible, peer-reviewed research and a reputable institution. Be wary of press releases, anecdotal reports, or media outlets known for sensationalism. Specifically for claims about SCAM, we might also add caution regarding the many third class SCAM journals.
Look for conflicts of interest
Investigate who funded the research and whether any authors or organisations stand to profit from the findings. Industry sponsorship can introduce bias, even in otherwise well-conducted studies. For claims about SCAM, we should remember that financial interest might be secondary to ideological ones.
Examine the study design
Consider whether the research used appropriate methods – such as randomisation, control groups, and adequate sample sizes – to support its conclusions. Observational studies, or case reports, or trials with the often-discussed ‘A+B versus B’ design, for example, cannot prove causation.
Consider the magnitude and relevance of effects
Distinguish between statistical significance and clinical importance. A tiny effect may be statistically significant in a large trial but meaningless in practice. Also ask whether the study population is representative and the outcome can be generalised.
Look for independent replication
Single studies should be treated cautiously until confirmed by other researchers. Consistent findings across multiple studies increase confidence in a claim.
Beware of over-interpretations
Scrutinise whether the authors or media coverage extrapolate beyond what the data support. For instance, generalising from animal studies to humans, or implying benefits without evidence of improved health outcomes.
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If I may, I will add an 7th to the six by the MJA. It is one that I have issued many times previously and that is, I think, essential in SCAM:
If it sounds too good to be true, it probably is!
Exaggerated or false health claims are endemic in SCAM. These 7 tips might be useful in disclosing them and in minimising the harm they can do.
People use unproven so-called alternative medicine (SCAM) even when evidence quite clearly indicates that the SCAM in question does not work.
Why?
Here are some of the factors that can play a role:
- The Placebo Effect Makes People Feel Better
SCAM “helps” even though it doesn’t work. The placebo effect is a real neurobiological phenomenon that can reduce pain, improve mood, decrease stress, and affect lots of other, mostly subjective endpoints. In some situations, placebos can be as effective as real treatments. This creates genuine subjective improvement that convinces many people the SCAM in question is effective.
- False Hope and the Need for Control
When conventional medicine offers little, people “grab at straws” because hope drives them. For seriously ill patients, suggesting unproven interventions can provide hope and a sense of control over their illness. The ritual involved in administering SCAM creates profound impact because people feel they’re getting the attention they crave.
- Confirmation Bias
People selectively gather evidence conforming to their beliefs, while neglecting contradictory evidence. If someone feels better after acupuncture, for instance, they attribute it to the treatment rather than natural recovery, placebo, the attention from the therapist, or simply the restful time spent on the treatment bench. Experience or stories from others bring helped by a treatment are not evidence, of course, but they can be very compelling.
- The “Expensive = Good” Heuristic
It feels reassuring to spend some money on one’s health. “If it’s expensive, it must be good!” Traveling abroad for exotic SCAMs creates hope through fundraising. And expectation boosts the placebo response.
- Anti-Science Beliefs Predict SCAM Use
Anti-science beliefs and conspiracy theories increase the willingness to take risks and try SCAM. People who are suspicious, untrusting, eccentric, and see the world as dangerous tend to see meaningful patterns where none exist. If you believe that Big Pharma is trying to kill you, you are likely to employ SCAM.
- Dissatisfaction with Conventional Medicine
It’s “frustrating and demoralising when medical therapies do not offer the benefits people need or expect”. When doctors can’t provide answers or effective treatments, people are likely to seek SCAM. Sadly, I have to admit that some conventional healthcare professionals can behave such that one simply cannot be surprised, if patients look elsewhere.
- Humans Are Wired to See Patterns
Humans evolved to quickly detect patterns and understand how events might be causally related. We seek explanations rather than seeing randomness, but this makes us prone to seeing connections where none exist. This cognitive vulnerability is why we mistake correlation for causation. We are easily fooled, and most easily by ourselves.
8. Misinformation
Over the years, I have come to realise that all of these factors – and many more – can play a role, but that none of them is as important as misinformation. SCAM has been in the limelight sice decades, and the public is bombarded with misleading information about SCAM. It comes from journaalists, book authors, influencers, marketeers, bloggers, social media, and many other sources. And it continuously brainwashes the public into believing that even the most deplorably useless SCAM is effective, safe, and supressed by the establishment. I sympathise with everyone who is being sent up the garden path in this way and thus may get deprived of his/her savings or – much worse – health.
As explained in my previous post, plausibility matters. The post was predominantly about biological plausibility – but things can be a little more complex, and it would be foolish to deny the fact that there are two kinds of plausibility; biological and clinical.
Biological plausibility concerns compatibility with established physiology, biochemistry, and pathology. It asks whether a credible pathway exists by which an assumed cause could produce an effect. And it takes into account current knowledge from biology and other natural sciences. Within the Bradford Hill framework, biological plausibility helps distinguish mere statistical associations from actual causes. For more details see my previous post.
Clinical plausibility, by contrast, is based on much softer criteria, such as clinical observation and real-world outcomes. Here, the core question is whether a claimed effect fits observed patient patterns, e.g.:
- temporal relationships,
- dose-response gradients,
- reproducibility across cohorts,
- alignment with known clinical phenotypes.
Supported by case series, observational studies, clinical trials, or epidemiological studies, an intervention can be clinically plausible long before its underlying biology is understood. This has historically been the case for many drugs; an apt example is aspirin which has been used clinically long before a biologically plausible mechanism was discovered..
The two forms of plausibility should be complementary. Ideally, a robust causal claim satisfies both mechanistic logic and clinical observation. Biological plausibility without clinical evidence remains speculative. Clinical plausibility without a known mechanism invites skepticism and further inquiry.
The deficit of biological plausibility is a major indictment of many forms of so-called alternative medicine (SCAM). They often offer no tenable mechanism and fail under rigorous testing. Conversely, demanding full mechanistic clarity before accepting consistent clinical data is likely to hinder progress in healthcare.
In relation to so-called alternative medicine (SCAM), the issue was summarised more than 20 years ago as follows:
In summary, the way to prove the efficacy of most CAM therapies is with well-designed RCTs, and there is no reason to believe that clinical trial designs cannot be developed that allow even complex CAM therapies to be evaluated. The procedures involved can be sophisticated, complex and expensive, however, and this confronts investigators with the challenge of identifying which of the myriad of existing and future CAM therapies merit the effort and expense of definitive RCT evaluation. The challenge should be met as it is in conventional drug discovery, through plausibility-building research. Whenever possible, efforts should be made to establish a credible mechanism of action for a candidate CAM therapy, because this will increase its biological plausibility and reduce the risk of false-negative RCT results. When biological plausibility is lacking, clinical plausibility alone must be the basis for determining whether or not to proceed to the costlier phase of definitive RCTs. The creation of a plausibility-building CAM research strategy will require thought, instruction, funding, and collaboration among conventional clinical investigators and CAM advocates. The advantages are many: fairness, low cost and the creation of rules of engagement for CAM evaluation that foster balanced partnerships between CAM advocates and mainstream clinical scientists.
Ultimately, in my view, not a dogmatic stance but a balanced integration of both biological and clinical plausibility should underpin rational decisions about which medical hypotheses to pursue, adopt, or discard.
Evidence‑based medicine (EBM) was developed to make clinical decisions more reliable by grounding them more solidly in good research. Thus, randomised clinical trials, systematic reviews, and meta-analysis became crucial for healthcare. That development brought undeniable progress, but it also created a problem: if we focus exclusively on such evidence, we might neglect an important question:
IS THE TREATMENT IN QUESTION BIOLOGICALLY PLAUSIBLE?
Put simply, EBM asks “Does it work in this study?” without first asking “Could it reasonably work at all?”
The neglect of biological plausibility can lead to wasted resources, misleading conclusions and, in some cases, the promotion of nonsense. The issue is, of course, particularly relevant in so-called alternative medicine (SCAM) known for its frequent lack of plausibility. A simple example might explain this more clearly: in homeopathy, we see an abundance of poor-quality studies with a positive result. This could easily lead to the overall impression that homeopathy works, while in fact it cannot reasonably work at all.
So, how can we reasonably take account of this complication? It turns out there are several options:
Option 1 Gatekeeping
One way to account for plausibility within EBM is to use it to decide what we test in the first place. Before launching an expensive clinical trial, we can ask for a clear explanation of how the proposed intervention might reasonably work. If no such rationale can be articulated without contradicting science, it is reasonable to conclude that the intervention lacks sufficient plausibility to justify the time, money and ethical burden involved in testing it on patients. In practice, this kind of gatekeeping often happens informally, but making it explicit and mandatory could help keep overtly implausible interventions from consuming scarce resources.
Option 2 Prior probability
Plausibility can also be integrated into how we interpret trial results. Some trialists treat a statistically significant result as an infallible signal that the therapy was effective. When a trial result is “statistically significant”, it means the data we observed would be unlikely if the treatment had no effect. Prior probability is another way of expressing plausibility. If a hypothesis is highly plausible given existing scientific knowledge, a positive trial fits into a broader, coherent picture. If a hypothesis is highly implausible, a positive trial is more likely to be a false positive, an artefact of bias, chance, methodological flaws, or fraud. In other words, for low‑plausibility claims, we need stronger and more consistent evidence before accepting them as true. The less plausible a claim is, the more extraordinary the evidence must be.
Option 3 Guidelines
Guideline development offers another opportunity to embed plausibility into EBM. When expert panels prepare recommendations, they typically grade the strength of evidence according to study design, risk of bias, and consistency of results. They might also add a distinct step in which they rate the plausibility of the intervention. This rating could be justified explaining how well the intervention fits with established knowledge. Guideline writers could then let this plausibility rating influence the strength of their recommendations.
Health technology assessments have been moving in this direction for some time. It makes guideline documents more transparent: clinicians could see not only what the trials showed, but also how the intervention was judged to fit into or contradict broader scientific understanding.
Option 4 Causation
Finally, causation frameworks are being used to bring plausibility into EBM. When we decide whether an association is causal, we often rely on criteria such as consistency, temporality and strength of association. Biological plausibility is another of these criteria. Using it systematically means asking whether there is a logical pathway from intervention to outcome that passes through known mechanisms and observed effects. If such a pathway can be sketched in a way that accords with science, plausibility is high. If not, plausibility is low, and we should be more cautious about drawing causal conclusions from statistical associations alone.
EBM has revolutionized healthcare, but evaluating evidence in a vacuum can carry the risk of validating the absurd. To minimise this risk, we might consider integrating biological plausibility into EBM, a possibility that has long been discussed by many experts in the field. This approach is not a rejection of EBM, but a vital safeguard for it which ensures that the evidence aligns with and strengthened by fundamental science and existing knowledge. By demanding extraordinary evidence for extraordinary claims, medicine can better protect its resources, maintain intellectual integrity, and ensure that clinical practice rests on a foundation that is both statistically sound and scientifically reasonable.
I suppose nobody need eplanations what the Epstein files are, or what crimes they depict, or how often Trump is mentioned in them. What many might not know is that even the United Nations (UN) have commented on these documents
Independent human rights experts, operating under mandates from the UN Human Rights Council, have warned that the Epstein files reveal evidence of a possible global criminal enterprise involving systematic sexual abuse, trafficking, and exploitation of women and girls. Due to the scale, transnational reach, and systematic nature of these atrocities, the experts stated that the documented conduct may meet the legal threshold for crimes against humanity. Under international law, this threshold applies to acts like sexual slavery, torture, and trafficking when committed as part of a widespread or systematic attack against a civilian population.
The disclosure follows the “Epstein Files Transparency Act” of 2025, which led to the US Department of Justice releasing over three million pages, 2,000 videos, and 180,000 images in January 2026. The background involves wealthy financier Jeffrey Epstein, who died by suicide in 2019 while facing minor-recruitment and sexual exploitation charges, and his associate Ghislaine Maxwell, currently serving a 20-year prison sentence.
The experts emphasized that states are legally obligated to investigate these crimes, which were fueled by corruption, supremacy, and extreme misogyny. They called for independent and impartial investigations into all individuals, financial structures, and official entities implicated, asserting that resignations are not a substitute for criminal accountability.
The experts praised the resilience of the survivors but criticized “grave errors” in the release process that exposed sensitive victim information, risking retaliation and stigma. They urged the adoption of victim-centered standard operating procedures for future disclosures and demanded that governments act decisively, declaring that no one is too wealthy or powerful to be above the law.
“Any suggestion that it is time to move on from the ‘Epstein files’ is unacceptable. It represents a failure of responsibility towards victims,” they said. “It is imperative that governments act decisively to hold perpetrators accountable,” the experts said. “No one is too wealthy or too powerful to be above the law.”
Trump and his team have repetedly responded to Epstein-file in general. Trump himself seems keen to disregard the experts, do precisely what they warned against, and move on. As far as I know, there is no statement of Trump or his team commenting directly on the UN experts’ “crimes against humanity” document itself.
An article entitled “Beyond the Appearance of Rigor: Trustworthiness, Integration, and Standardization in Traditional, Complementary, and Integrative Medicine” caught my eye. The name “Traditional, Complementary, and Integrative Medicine” is, I think, impressive as it demonstrates the seemingly infinite ability of SCAM-promoters to come up endlessly with new and ridiculous terms! Please allow me nonetheless to continue calling it so-called alternative medicine (SCAM).
The paper itself might be summarised as follows:
SCAMs struggles to fit into mainstream science. Trustworthiness isn’t just about flashy, individual study results; it requires a reliable system of transparent data and independent replication. However, forcing SCAM into mainstream healthcare via scientific scrutiny, standardisation and integration is a double-edged sword. It strips away the personalized, holistic essence of these therapies. Instead of abandoning science or changing the therapies, researchers need to use creative, flexible scientific methods that document the real-world complexity of SCAM without trying to force it into an artificial mold.
I have heard this argument often, particularly early on when I started applying science to SCAM. SCAM proponents were initially taken by the idea; later, when the results were often not what they expected, they were less impressed and argued that, because science failed to produce positive results, something must be wrong with it and in need of improvement. Specifically, the arguments were:
- SCAM is individualised,
- SCAM is holistic,
- SCAM is complex,
- SCAM is subtle,
- SCAM depends on the skill of the practitioner.
And therefore, SCAM cannot be fitted into the straitjacket of science, particularly not in the one imposed by the randomised clinical trial.
It took many years to convince some SCAM proponents that these notions were erroneous, that science is not always perfect but that no better method for testing exists, that many mainstream interventions (e.g. physiotherapy, psychotherapy) are just as complex, holistic, etc. as is SCAM. Eventually the argument that SCAM defies scientific evaluation disappeared – not totally, but almost.
Now, 30 years later, it is back!
One cannot even blame the SCAM enthusiasts for reviving it. Thirty years of research and very little of SCAM has been proven to work – unless one gives SCAM a huge ‘benefit of the doubt’ and pretends poor science constitutes proof. Even the treatments that SCAM proponents celebrate as evidence-based fall apart once we scratch the surface and discover how poor and irreproducible the evidence mostly is.
Yes, I do sympathise with the frustration of SCAM proponents as they gradually realise all this. Many of them know only too well that their most solid evidence can be taken apart by any first-year medical student with rudimentary skills of critical evaluation. Many of them therefore have long moved away from hypothesis testing research and prefer the type of investigation that never generates a negative finding (e.g. surveys, qualitative studies, sociological approaches). Others, including the two authors of the above-mentioned paper, prefer to go full circle and revive the notions we dealt with decades ago claiming we need different standards for SCAM than for the rest of medicine.
Perhaps someone should tell them that double standards are never a good idea?
