Several months ago Robert Imrie, DVM, of our editorial staff assented to this communication. In a message to him, you commented that strong or emotional language describing “alternative” medicine was counterproductive.
I send this in the hope of shedding some light where resides the monster in the closet—the differences between journalism’s ethics and standards and medical science; the reasons journalistic standards fail us. The problems should concern both parties. Although we may start from the same base, our problems result from travel along diverging roads. There are reasons for strong words.
The agreed principle—the starting point—is to find the truth, or to approximate it as closely as possible. From examining press reports on sectarian systems and implausible methods (what you would call “alternative” medicine), I have come to the following conclusions:
- The press approaches truth through principles of “balance” and “fairness” and assumes objectivity is satisfied and veracity will follow. Objectivity is not a measured quantity and veracity is not an independent goal.
- The press approximates veracity by checking with more than one source. If sources disagree, both are presented and veracity is left up to the reader.
In the first divergence, medical science functions through objectivity and veracity. Personal observations and testimonials are less valued. Medical science depends on scientific method: accurate observation, mathematical analysis of data, inductive reasoning, experiment (hypothesis testing), repeatability, and deductive reasoning. This sounds complex, and it is. It is more than asking questions, then finding another confirming source. Objectivity and veracity are primary and measured.
One can see how these two approaches conflict in examining “alternative” medicine. “Alternative” medicine values subjectivity, intuition, and other avenues of collecting information. Knowledge and wisdom, characteristics of science’s “logical positivism,” are not valued.
A press report starts with the assumption that the “alternative” movement is somehow equal in veracity—or least separate and comparable in some ways—to medical science. Medical science, however, regards complementary and “alternative” medicine (CAM) differently. For 400 years, physician scientists and practitioners succeeded in separating the principles on which “alternative” medicine is based—personal observation, religion, faith, belief, transcendentalism, feelings, hunches, intuition, incorrect premises and erroneous concepts, and social delusions (all qualitative aspects)—from objective observation and reason. This separation assured, for the first time in history, an accurate approximation of truth and reality, and thus the making of correct decisions. Note here that in science and medicine, there is no such principle as “balance” or “fairness.” We argue a lot. We sometimes use strong words toward one another.
We have found through psychological research, mathematics and statistics, and learning from unfortunate errors and deaths that humans are poor observers, even more so of themselves. That is why self-diagnosis and folk treatments, except for minor conditions, are discouraged. Objective measurement and repeatability by others have become the foundations for knowledge and the basis for decisions and actions. This recognition is a transcultural, international consensus. Although the concept arose in European tradition, almost all nations and cultures now accept it. Those who deny the consensus are of three categories: ideologues, pretenders, and . . . well, people who are not very smart. Strong words, yes, but others muffle the real differences. Try: people whose heuristics disallow incorporation of disconfirming information; people who, in pursuit of idealistic and other goals, prefer to disguise their intentions in specific endeavors; and people who may have selective intellectual handicaps. When alternativists and cultural academics describe themselves, they are likely to use such semantic inventions.
The next principle is plausibility. Most anomalous methods are proposed because someone made erroneous observations or arrived at an erroneous interpretation. They often contradict established laws of nature. Claims for them are implausible. Chiropractic, homeopathy, and acupuncture all are, at base, derived from observational errors. Most advocates of these systems ignore the basic clinical science that make their principles and methods implausible. Sometimes strong words are used to distinguish them from medicine, because the advocates do not listen, do not change in the face of contradicting facts, but continue to justify themselves and rationalize their positions.
Let us imagine an observational error independent of known CAM systems for illustration. It will lead into another aspect of the current dispute: the ill-conceived role of government. Imagine that one observes garden spiders in a tomato patch, noting that each morning the leaves have more areas nibbled away—lost to some agent. The observer sees spiders and webs on the surface. The observer therefore concludes that the spiders did it. But we know from observing all other spiders that spiders do not eat tomato leaves; they eat insects and the like. And the more insects there are, the more spiders move in on them. (Whether spiders eat tomato worms or not, I do not know, but stick with this.) On the other hand, the observer either does not know that fact or rejects it. He then constructs an experiment to show that spiders eat leaves at night by observing the leaf surfaces from above each morning. Indeed, the plants show more leaf damage along with more spider webs. A new principle is discovered!
In this case the experimenter did not entertain alternative, simpler explanations. He made no allowance for inspection of the underside of the leaves for caterpillars or worms. One can see that the experimenter erred, so the observer erred and reached incorrect conclusions.
The same thing is happening with CAM at the National Center for Complementary and Alternative Medicine (NCCAM). Bad experiments based on incorrect assumptions are leading to conclusions equivalent to the discovery that spiders eat leaves, whereas we know that there is another explanation for the observations. To make matters more irritating, we know already that the methods being investigated do not work, and that some clinical trials with incorrect setups will get erroneously positive results. The experiments are neither necessary nor indicated. In addition, some are repeats of clinical trials already done. Research grants are being awarded to people not competent to carry out the trials. NCCAM appears to be merely looking for ways to spend the grant money authorized by Congress. But we can go further: Even good projects are not necessary because we already know what the results will be and, if not as expected, we will find the responsible errors. The same thing happened with Laetrile and vitamin C for cancer in the 1970s and 1980s, when unindicated trials cost millions.
The press perceives the National Institutes of Health (NIH) placing importance on “alternative” approaches because of the more than $100 million per year being spent on it. Wrong: congressional members appropriated the money because of political pressures from the “alternative” community. The press attributes the highest of motives and degree of veracity to the NIH, which, in this instance, is controlled by politics.
In spite of the fact that we already know the methods do not work, and the reasons why, hundreds of millions of tax dollars are being used to promote their reputations and to incorporate them into practice. The press and others are not listening. Is that not, shall we say, just frustrating? How can scientists speak without frustration and in moderate tones about situations in which proponents reject logic and reason, and the press does not listen and continues to report misinformation? How can we be calm when even medical school deans get swept along (Harvard, University of Arizona, Columbia, University of California) by millions of dollars in NCCAM and private research grants? How does one use reason in presence of a social delusion? Strong language comes naturally.
To those who object to strong language, we can show that supporters of “CAM” are either not very smart, are poor physicians (I have met many as an expert witness in bad doctor trials) or ideologues, or are misled or partially delusional. These are strong words, but euphemisms simply do not work here. How else can one describe them? Can anyone substitute words that are accurate, and mild, but carry the same meaning? Are advocates just people with differing opinions? That is what some seem to want us to think and say. Rational medical scientists must speak in moderation when responding to advocates who err and lie.
“Alternativists” cloud their errors, falsehoods, and misrepresentation in obscure language and shifting definitions. They model words like clay, dissolve rules of scientific evidence, and erase common sense. This way, they can verify their claims without measuring according to the rules. They do this most easily by first misusing, then actually redefining words. We have in their own writings admissions that they have intentionally changed the language of the commons, from quackery to holism, to alternative/complementary, to integrative. What could not be accomplished in the courts of scientific evidence and rationality, they accomplished through semantic trickery.
Strong words, but what else suffices? This system of redefinition is a hallmark of postmodernism, as you probably know. The CAM movement is a trailing edge on the wing of the relativistic, postmodern culture and science wars taking place in academia. Through restructuring of language, it will restructure thought. Its intent is to misrepresent through confusion, to dominate and direct a radical change in health and medicine. Its advocates see nothing wrong with it. But they know it, and we know it.
This activity is not just intentional, but also intentionally hidden from public view. What the press needs to know, but I have rarely seen acknowledged, is the fact that “alternativism,” a derivative of the 1960s mind-bending movement and mentality, also rides on the 19th-century theosophist movement as well as the postmodern wave. It has declared war on rationality. No matter what else one might want to call it, this is the situation, and other descriptions are masquerades.
Part of the press’s failure derives from its focus—an essentially anti-Establishment orientation. Trained to doubt people in authority and to question the status quo because they could be hiding something, reporters and editors often regard medicine as the party of the status quo. In this case, the press’s concerns are inverted, and its actions are misdirected. Medicine’s sores are visible on its skin. Alternativism’s corruption is buried beneath its euphemisms. The press colludes in interpreting science and rationality as dominant, hegemonic, monopolistic, reductionist, conventional, orthodox, authoritarian, paternalistic, and arrogant; an economically motivated “Medical Establishment.”
“Alternative” advocates use these terms freely, without challenge. But this is strong language, rarely reacted to by the press.
The truth is, there is no Medical Establishment conspiracy. Medicine is an open, internally contentious, constantly changing endeavor. The CAM movement, along with its political and social reformer allies, its radical motivations and delusional characters, challenges the heart of the enlightenment and rationality. Indirectly, it challenges other institutions of civilization. Not a global misrepresentation, this is an accurate description of the innards of the problem.
The press has been swept along in this, confused by the semantics and seduced by the thrill of exposing a part of the “Establishment” as pretentious. That is where the press, the very institution we rely on for investigative unmasking, has failed us. The press, while looking askance at other activities—from Enron executives to corrupt politicians to psychopathic murderers, has been marvelously gulled by “alternative” medicine.
The press’s ideal role is still similar to that of science—the best estimation of the truth. But its modern methods are defective. Approximating the truth through “balanced” reportage has resulted in error and implausibility receiving the same weight of credibility as reality through reason and science. As an example, let us take the history of acupuncture.
The latest interest is attributed to James Reston’s appendectomy in China in 1972, supposedly using acupuncture anesthesia. You probably already “know” that he received it only for postoperative cramps. Well, even that is inaccurate. In his report, he did not use the words “pain,” “cramps,” or even “discomfort.” He said “distention.” He recognized that distension was normal after an abdominal operation, and the time it took to relieve it was consistent with the time if nothing was done. He stated that the effect probably temporarily distracted him from the distension (simple counterirritation, and he recognized it). He got it right, and everyone since then has gotten it wrong. Why? You now know as well as I. What was originally a simple reportage was remolded and massaged by others until it became what they desired it to be: a man-bites-dog story, an apocryphal tale, an urban legend metamorphosed into only an approximation of the “truth.” It persisted because people wanted it to, and the press did not do its homework. The original article, found on microfiche in the Boston Public Library, was reported to me by our colleague and associate editor, Kimball Atwood, MD.
We have done the homework. We know that 14 reasons already exist to explain why someone would perceive that acupuncture might work. None involves complex nervous system explanations or endorphins. None involves Q’i, yin and yang, or imaginary meridians and points. The mechanisms are nonspecific, proved by psychological and physiological experiments. You probably could name 7 of them yourself. When one discovers the frank fakery presented to foreign observers of Chinese operations (suggestible volunteers who received additional analgesic medications) and stories constructed for political purposes by the Chinese regimes (admitted to by the physicians involved), one does not need to do 400 clinical trials. But we do indeed have at least 400, with 33 systematic reviews for 17 different conditions. For only 2 conditions do a majority of trials show more effect for acupuncture than for sham controls. In a recent review in the Scientific Review of Alternative Medicine, David Ramey, DVM, showed why those few are positive—and it is probably not the acupuncture, but, rather, chance and error. Yet the Food and Drug Administration (FDA) reclassified acupuncture needles from experimental to approved on the basis of this flimsy evidence. Eleven states now license lay acupuncturists. In 1997 the OAM/NCCAM convened a consensus conference consisting entirely of proponents. They declared acupuncture effective for several conditions. Several insurance companies began paying for acupuncture. The same is happening with chiropractic, which is 10 times as popular.
More than 100 controlled trials of homeopathy and more than 100 trials of chiropractic manipulation show that the tightest, most well done trials are negative. Only the loosest and poorest conceived trials are positive. It is the same for group therapy for cancer patients, Therapeutic Touch, prayer, distant healing, and the rest. Hundreds of trials performed, none of them with necessary or qualifying plausibility, most of them negative, and still $150 million per year is being poured into more research.
This is a partial view of what we already know. And yet, although the proponents all know us and we are in many Rolodexes, few of us have been the subjects of news articles or programs. We are called for “balance” when a pseudomedicine or practitioner is written up. We are then called naysayers, quackbusters, and “self-proclaimed skeptics,” rather than experts in scientific method and observation. Our comments are most often buried in one or two paragraphs in the middle a 30-plus paragraph article. Advocates do not tell reporters we exist. We are fortunate to be called at all.
In your exchange with Dr Imrie, you expressed that his presentation and our several press releases on the White House Commission on Complementary and Alternative Medicine Policy, appeared to be “biased.” “Basically,” you wrote, “you would get a better reception from journalists if you gave less biased material backed up with actual documents, not diabtribes [sic]. Think JAMA article, that’s what journalists like me need to receive [sic] from activists like you—even doctor-activists.”
Activists? We have to add that one to the list of off-base, unwarranted descriptions. Biased? There is no bias here. There is educated knowledge. The bias is in the language you used—you, who, I am sure, believe yourself to be an accurate and unbiased reporter.
The facts are as we state them. The proponents misrepresent, and we are calling them on it. If the press were to do its assumed duty to the public, it would expose the situation for what it is, and then we would not have to shout.
Wallace Sampson, MD
Editor, The Scientific Review of Alternative Medicine