Evidence, Not Anecdotes

This post is part of our forum on David H. Freedman's July/August story, "The Triumph of New Age Medicine." Follow the debate here.

I don't have much to say about Steven Salzberg's claim that I "masterfully" manipulated the argument, because I'd rather focus on the evidence and reason he presents to back that claim up. Unfortunately, he hasn't given me much to work with, and in fact offers nothing that wasn't clearly spelled out in my article.

He provides a handful of anecdotes (oddly, given that he seems to object to my including anecdotes in the article) that people have been harmed by alternative medical practices, a risk that I prominently discuss in the article - and that seems, according to research, to be a tiny one that pales alongside the risks of being harmed by a mainstream drug or surgery that probably wasn't necessary and had little chance of helping much.

I rely far more on mainstream study findings than on anecdote in my article to make that point and others, for what that's worth. But I encourage readers to not take either my or Salzberg's word for the relative risk of harm in mainstream and alternative medicine - there are plenty of studies available online. (With the caveat that going to a website with overt biases for or against alternative medicine will produce predictable results. For example, see this post for an example of a response to my article that does away with all pretenses of objectivity, civility, or respect for evidence and reason. I appreciate that Salzberg, in spite of his strong feelings, stays far above that sort of venomous, unscientific nonsense.)

According to Salzberg, my article falsely implies that he (and presumably other critics of alternative medicine) opposes every treatment that hasn't gone through randomized trials. But I don't say that in the article. In fact, I specifically point out that one-fifth of the prescriptions written by physicians in the U.S. are for off-label applications that have not been supported by randomized trials.

What I do clearly suggest, with the explicit support of many prominent researchers and physicians, is that alternative medicine probably can't be dismissed even when randomized trials seem to show that it doesn't work better than placebo. That's not only because the placebo effect itself can be so powerful and helpful in alternative medicine (and of course, it plays a large, if less-powerful, role in mainstream medicine as well). It's also because randomized clinical trials can't fairly assess the components of alternative medicine that seem to do the real good: strengthening practitioner-patient bonding, promoting healthier habits, and addressing stress, anxiety, and other thoughts, feelings, and attitudes that can seriously compromise health, according to a wealth of research. (Research that Salzberg wisely does not try to dispute.)

Salzberg also implies that my article falsely presents all alternative treatments as equally valid, though neither I nor anyone I quote in the article makes such a fuzzy claim. Then he goes on to implicitly define "valid" for us: a treatment whose mechanism is plausible. He singles out homeopathy as relying on a patently implausible mechanism, namely the administering of a glass of water with undetectably low levels of some compound.

But my article clearly explains that the benefits of homeopathy, and probably of massage therapy and hypnosis (two alternative treatments Salzberg seems very comfortable with), rely on the placebo effect and the practitioner-patient interaction, not on the details of the treatment. If he wanted to deny the plausibility of those mechanisms, he'd have a lot of explaining to do, given the large body of evidence that supports them.

Since Salzberg has not, in my opinion, highlighted any real weakness in my argument, let me do it for him. I think the weakest part of my argument is the notion that mainstream physicians can't do as good a job as alternative practitioners in enlisting the placebo effect, inspiring behavior change, and promiting healthy attitudes in order to head off complex, chronic illness before it takes hold. Physicians seem to agree that they are constrained by the current healthcare system from easily doing so, but in principle they could do much better as a whole - and many, many individual physicians already do a terrific job along these lines. For instance, I would choose Steven Novella, the Yale neurologist I quote in the article, as my personal physician in a heartbeat over any of the alternative practitioners I met. He came across to me as an extraordinarily caring and competent physician who works hard to get patients acting and thinking in ways likely to help their health, rather than routinely slinging scrips and scalpels in all directions I suppose I could have "masterfully" spun the article to emphasize that point, but instead I put aside my personal biases and strove to be objective. Would Salzberg claim the same of his approach to alternative medicine?

The debate continues here.