Does the Truth Matter?

One of the most common responses I get when I point out the lack of evidence for particular CAM therapies is, “So what? If it doesn’t do any harm and if people feel better, even just because of a placebo effect, then why do you want to convince them this stuff doesn’t work?”

Of course, the first answer to this has to be challenging the assumption of safety which seems to adhere to most CAM therapies, and I have done that at length. However, beyond that issue, it seems to me a fair question whether the truth matters when it takes away something benign that people want to believe and which might offer some relief from symptoms via a psychological mechanism, if not by way of actually changing the underlying disease process. I have several answers to this question, some personal and philosophical, others more pragmatic and directly relevant to medicine.

On a personal level, I share the sentiments of R. Barker Bausell, author of Snake Oil Science. He sees investigating the truth about the claims of alternative medicine as part of the larger project of science, and his research and writing are motivated at least “partly [by] a common professional objective for a scientist: to be able to claim a personal victory in one small skirmish in the perpetual struggle between knowledge and ignorance.” Though I understand that many, perhaps most, people don’t share the sentiment, a lot of us in science are driven by a visceral sense that truth matters, and that even unpleasant truths are to be embraced and comforting untruths disdained. I don’t see imparting this sense to others as a core goal, or justification, for challenging bogus medical claims, though I do hope my passion for what is true may resonate with some readers. But I must be honest and confess that this feeling is a large part of why I engage in my various projects promoting science-based medicine.

On a more practical level, there is clear evidence that the comfort taken from untrue beliefs in medicine does harm beyond the direct damage particular medical therapies may cause. While some turn to CAM only when they have exhausted the options provided by science-based medicine, CAM therapies are often promoted as an alternative to scientific medicine. However, when CAM is used in lieu of the more effective, better understood therapies of scientific medicine, people suffer and sometimes die unnecessarily. We see this happen in the asthma patients who have poorer compliance with drug therapy, and poorer quality of life scores, then they substitute herbs for medicine, and in the cancer patients who eschew effective mainstream treatment or palliation in favor of alternative therapies, leading to greater suffering and earlier death. What is more, because CAM therapies are so amenable to placebo effects and to false assessments of real efficacy, even casual experimental use in conjunction with conventional therapies can lead to a belief in not only the efficacy of the alternative interventions but create sympathy with the philosophical underpinnings of these interventions and skepticism of the underlying foundations of science.

CAM proponents frequently emphasizes supposed philosophical differences between alternative medicine and science. Some of these are marketing points rather than true differences, such as the nonsense about CAM treating the whole patient rather than just the disease, or scientific medicine treating only symptoms while CAM treats root causes of illness. However, there are some genuine philosophical differences between science as an epistemological approach and the world view of many CAM adherents. CAM often rests on a foundation of vitalism, the notion that invisible spiritual or “energy” forces are the true source of animation for living beings, and that disease is not a manifestation of disorders in the physical body but in these mystical forces. Vitalists claim to be able to sense and manipulate such forces, but these claims are never demonstrable by any objective means and must be accepted on the basis of faith alone.

This is in contrast to the position of methodological naturalism, in which scientists agree to put aside any personal intuition or revelation of a spiritual nature when investigating and treating the causes of disease, and focus solely on mechanisms and causes which can be objectively and repeatedly demonstrated to anyone. The claims of some CAM advocates that this approach is doomed to failure because it ignores the “real” nature of life and health are belied by the astounding success of the technology and medicine it has generated. Millennia of vitalist approaches to medicine failed to achieve the improvements in health and longevity a naturalistic approach has accomplished in only a couple of centuries. There’s a reason why mystical health care theories have had more success being adopted in the treatment of chronic diseases, particularly involving subjective symptoms like pain, and have failed to be widely accepted in acute, life-threatening situations. Homeopathic birth control hasn’t caught on too well either, so perhaps there is more to be said for “reductionism” than CAM proponents often credit.

Yet vitalist philosophies have an emotional and aesthetic appeal, and I understand the historical and psychological reasons they are so attractive and widespread. Nevertheless, I feel the evidence of history conclusively demonstrates naturalism to be a more accurate and successful model of reality, and there are real dangers in choosing to ignore this reality and adhere to comforting but unsuccessful paradigms when dealing with health and disease.

Similarly, many CAM advocates hold to an extreme relativism born of the post-modernist philosophical movement. This sees all models of reality as purely social constructs with no sound basis to give preference to one over another. Any attempt to assert one model is more faithful to an objective physical reality than another is dismissed as merely an attempt to justify a particular social and political power structure, to the advantage of one cultural group over others. Thus, even claiming objective reality exists and can be described is denounced as a form of political and cultural oppression. All points of view are held to be equally valid, and no truth claims are defensible.

This philosophy has had much success in the rarefied air of academe, though even there it is beginning to fray. It is buttressed by the reality that all of our models of reality are in fact  influenced by cultural factors, and that oppression is often justified by its intellectual apologists through the promulgation of scientific and pseudoscientific theories. However, postmodernism throws the baby out with the bathwater, and in an attempt to eliminate xenophobia and ethnocentrism it eliminates any hope of understanding the universe or improving our lives. Again, the history of science, technology, and medicine clearly and forcefully demolish the notion that there is no objective reality and that we can have no true knowledge of it. Such a perspective has no usefulness, and should have no place in medicine.

On a more practical level, one reason to care about the efficacy of CAM methods is simple economics. A 2009 study from the NCCAM found Americans spent $33.9 billion on “alternative” therapies (though the definition used in the study was quite loose). This is a lot of money to put into treatments of dubious effectiveness, and even if they have some positive effects in terms of subjective symptoms like pain or nausea, I think it is fair to wonder whether such resources could be better spent discovering more effective therapies or making health care more available to those who cannot afford even basic care.

Finally, Simon Singh and Edzard Ernst make the case in Trick or Treatment: The Truth about Alternative Medicine that it is nearly impossible to benefit from the placebo effect of a medical therapy without either lying to the patient or at a minimum deliberately ignoring the evidence against the placebo therapy. Most CAM practitioners obviously genuinely believe their methods work. However, maintaining this belief requires ignoring the principles and practice of science and evidence-based medicine. In today’s world, with the knowledge that scientific research has accumulated in the last few hundred years, sticking with such an attitude requires a kind of deliberate ignorance. CAM practitioners who utilize clearly disproven methods or concepts, such as homeopathy, the vertebral subluxation, and so on, must reject the very principles of science and the most basic, and well-established scientific understanding of the world. This is an act of faith that makes their approach more of a religion than a medical science.

There are those who honestly try to apply the principles of science and evidence to CAM. Unfortunately,  there are few CAM therapies that one can honestly justify in this way. Acupuncture for pain and nausea, chiropractic for idiopathic back pain, and a few well-studied herbal remedies and nutritional supplements are about all CAM can justly claim to be supportable by any sort of real research evidence, and even some of these claims amount to a primarily psychological, rather than disease-modifying, set of effects. There are important ethical questions associated with the use of placebo therapies, whether in mainstream medicine (where antibiotics and vitamins are often used to this end) or in CAM (where arguably the majority of the benefits seen are placebo-based). As I’ve argued before (here and here), the benefits may well be outweighed by the harm done to the caregiver/patient or client relationship by introducing deliberate deception, or even more the more subtly disingenuousness in sticking with what one’s experiences and intuition say and ignoring robust evidence against one’s approach, into this relationship. Though it is a philosophical point, and as such not provable in any objective way, I cannot help but feel that we are better served by honesty and a commitment to the truth than by accepting the short-term benefits associated with deceiving others or even ourselves.

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