(This email is part of a series of emails on medical pseudoscience, and a continuation of my last email.)
I have been writing about medical pseudoscience for over twenty years now. The typical response I get is, “What's the harm Dr Woolf? So what if pseudoscience produces medical treatments that probably don't work. At worst, it can provide a comforting placebo. Don't you want your patients to feel better?” Actually, there are several harms of medical pseudoscience. Let’s review them.
Placebo effects can hide underlying pathology
Placebo effects are certainly not exclusive to pseudoscience-based treatments. All treatments can generate a placebo effect. However, relying exclusively on placebo effects to treat patients can be dangerous. The placebo effect is only psychologic, not physiologic. This means a sick person can "feel" better, when in reality, they are still sick and should be seeking proper care. A classic example of this phenomenon is seen in asthmatics. When given a placebo, asthmatics will report feeling better, but they will have no objective improvement in their pulmonary obstruction (peak flow). With almost 500,000 asthmatic deaths per year worldwide, a false perception of improvement can be deadly. It's always preferable to use a science-based treatment. It provides both a placebo effect and a real effect.
A science-based treatment is always preferable. It provides both a placebo effect and a real effect.
Prescribing a placebo is unethical
Research shows that the most strong determinant of the placebo effect is the confidence of the practitioner and how positively they communicate the effect of the treatment. This means that the more the practitioner exaggerates the benefits of the placebo, the more likely the patient is to respond. Thus, the placebo effect relies on deception, ignoring informed consent, and disregarding patient autonomy. In medical ethics we call this, “lying to your patient”. Therefore, exaggerating the benefits of pseudoscience, treatments with exceptionally low probabilities of working, is "lying to your patient".
Practitioners of pseudoscience, like Deepak Chopra or Andrew Weil, do not agree that it is lying. To them, the placebo is powerful and it IS the treatment. But think about the double standard here. Image if Merck did a study on their allergy drug Claritin, and found that it worked, but no better than Placebo Claritin. Then, Merck starts selling Claritin and Placebo Claritin claiming, “they both work, you can buy either.“ Furthermore, the placebo effect is not a as powerful we think. A meta analysis of 200 trials showed that, when properly controlled, there is no placebo effect, especially for objective or physiologic outcomes.
Once again, it is always preferable to use a science-based treatment. It has a placebo effect, a real effect, and avoids the ethical dilemma of lying to your patient.
Misdiagnosis
Pseudoscience does not only offer treatments, it offers diagnoses. In science-based medicine, there are many signs and symptoms difficult to diagnose: fatigue, obesity, “brain fog”, or bloating. Pseudoscience tries to fill in these knowledge-gaps by offering diagnoses; adrenal fatigue, multiple chemical sensitivities, gluten sensitivity, MSG syndrome, leaky gut, chronic lyme disease, or candida syndrome. However, these diagnoses are notoriously dubious. They lack validation, and when validation is attempted, they are mostly proven wrong.
The reason this is problematic is that there exists a cognitive tendency, even amongst the most experienced diagnosticians, to latch on to the first diagnosis they come across. This is known as premature closure, and it is the most common reason for diagnostic error. Like with horoscopes, we tend to think a diagnosis fits us perfectly, even though the symptoms are vague enough to describe anyone. Furthermore, we prefer any answer over no answer at all, so a dubious diagnosis will always win over no diagnosis. With the rise of the internet, my patients frequently arrive at their appointments, already self-diagnosed, with a pseudoscience-based diagnosis. These diagnostic errors are extremely important, because once you start out with the wrong diagnosis, everything else that follows will be wrong.
Once you start out with the wrong diagnosis, everything else that follows will be wrong.
Opportunity costs
There are opportunity costs to pseudoscience. Providing a diagnosis unlikely to be true, or a treatment unlikely to work, wastes both time and money. It can prolong needless suffering, or even worse, miss a window of opportunity for a time-sensitive problem... like cancer.
Steve Jobs provides us with the best example of a missed opportunity. As reported by his official biographer, Walter Isaacson, Steve Jobs delayed the surgical treatment of his pancreatic cancer when it was still resectable. Instead, under the advisement of his acupuncturist, he opted for acupuncture and a vegan diet. A decision he would later regret. After one year, he was rescanned and his tumor had spread to the liver. At that point, it had metastasized and was considered unresectable. So much for the rich and powerful getting the best medical care.
A confidence trick leading to future bad decisions
We have all heard the term “con game” or “con artist”. The “con” is short for confidence. The goal of the confidence game is pull a confidence trick - establish confidence in a person, and later on, leverage that confidence when the stakes are higher. This same process is evident in pseudoscience. The pseudoscience-based practitioner establishes confidence in patients by treating conditions that are typically prone to placebo or tend to resolve on their own: back pain, fatigue, anxiety, or the common cold. To further ensure success, they often add universally helpful science-based lifestyle interventions, such as exercise, diet, sleep, and stress management. When all is said and done, the patient feels better, the pseudoscience took credit, and the patient now has confidence in the pseudoscience. When a higher stakes circumstance arises in the future, such as cancer or a serious infection, the patient will choose the pseudoscience.
Again, Steve Jobs‘ tragic story provides us with an excellent example. He was enchanted with the philosophy of the east, and started to use an acupuncturist for benign conditions such as back pain and nausea with good results. This built up his confidence in acupuncture and his acupuncturist. When he was later diagnosed with cancer, it was natural for him to turn to the practitioner that had not failed him yet. Pseudoscience played a confidence trick that lead him to make a bad decision for a future serious condition.
Pseudoscience plays a confidence trick leading to bad decisions for future serious conditions.
Direct side effects
Pseudoscience-based medical treatments, like all treatments, have side effects. As explained prior, the human body is a complex system in homeostasis; anything that disturbs this balance can potentially cause harm. This website provides an extensive list of documented side effects from every pseudoscience imaginable. The side effects cross the spectrum of severity: skin burns from cupping, kidney failure from chelation therapy, stroke from chiropractic neck adjustment, to death from detox cleanses.
However, we must acknowledge that the side effects we are witnessing are just the tip of the iceberg. This is because pseudoscience-based treatments lack large clinical trials (our best tool for determining side effects), and have no formal side effect reporting system. As I explained in the prior email, pseudoscience makes no attempt to disconfirm itself, and by the same token, makes no attempt to prove itself unsafe either. If you don’t go looking for side effects you won’t find any.
We must acknowledge that the side effects we are witnessing are just the tip of the iceberg.
In fact, pseudoscience has even managed to switch the legal burden of proof and create a double standard. Supplements, for example, are legally considered safe until proven otherwise, whereas prescription drugs are considered unsafe until proven otherwise. Yet, both are concentrated chemicals that alter homeostasis and can have harmful effects.
Anti-science thinking
It is almost essential for pseudoscience to be accompanied by anti-science thinking. It is a necessary defensive strategy. By definition, pseudoscience lacks strong evidence and is threatened by peer review. Therefore, it’s only recourse when challenged, is to discredit science or make logically fallacious arguments. Typical arguments include: denying the scientific hierarchy of evidence, appealing to false authority, applying magical thinking to explain the implausible, and when all else fails, launching ad hominem attacks and conspiracy theories against science.
Because pseudoscience lacks strong evidence, and is threatened by peer review, it’s only recourse to challenge is to discredit science or make logically fallacious arguments.
Of all the harms of pseudoscience, anti-science thinking is the most harmful. The reason for this is that anti-science thinking convinces the patient that pseudoscience is, not just the superior choice, but the only choice. It convinces them to abandon lifesaving science-based diagnoses and treatments. Beliefs like these can be quite hazardous to your health. For example, a cancer patient indoctrinated with anti-science thinking, “Big Pharma has the cure to cancer and is keeping you sick with chemotherapy for financial gain“, will not only prefer alternative medicine, but they will use it exclusively. When this happens, these patients are at a 250% increased risk of death.
Anti-science thinking makes pseudoscience, not just a superior choice, but the only choice.
But how prevalent is this kind of thinking? With the recent COVID pandemic, it would appear very prevalent, and very recent. However, the truth of the matter is that anti-science and conspiracy thinking is rather insidious in nature, and was quite prevalent even prior to COVID. A survey published in JAMA in 2014 found that 37% of the US population believed Big Pharma.had the cure for cancer and was conspiring with the government to suppress it. The message here is that with time, any good person, with good intentions, can be slowly indoctrinated.
Medical pseudoscience on the rise??
Despite the above harms of medical pseudoscience, and the incredible results of medical science, it actually appears that medical pseudoscience is on the rise. The reasons for this are complex and multifactorial. However, an expansion of our freedoms over the past several decades appears to be the one overriding factor. Stay tuned, this will be your next email, "Why medical pseudoscience is on the rise".