Though it’s certainly not an original observation, I’ve begun to see some repeating patterns of behavior associated with unreliable and unscientific medical claims, and I think it might be useful to review some possible warning signs that one is dealing with quackery or nonsense. Certainly, not all of these markers will be found in the claims or marketing of every unsubstantiated medical approach, and some of them may well be found attached to legitimate or correct claims. However, viewing hem as risk factors or red flags can help one to separate the pseudoscientific from the scientific and the truly helpful from the nonsense.

1. The Galileo Complex-

Most idiosyncratic ideas that conflict with the mainstream understanding of reality turn out to be wrong. As Michael Shermer puts it: “History is replete with tales of the lone scientist working in spite of his peers and flying in the face of the doctrines of his or her own field of study. Most of them turned out to be wrong and we do not remember their names…The person making the extraordinary claim has the burden of proving to the experts and to the community at large that his or her belief has more validity than the one almost everyone else accepts.”

The exceptions stand out precisely because they are exceptions. People with questionable ideas like to compare themselves to Galileo or other historical figures who were widely doubted and whose ideas were vilified and suppressed in their own era but who were later vindicated by science and history. This is a neat little bit of self-aggrandizing spin that is a lovely example of the availability heuristic and cherry picking fallacies. Because such cases are unusual, they stand out in our minds, which makes us likely to see them as more common or representative of the norm than they are, and because we wish to validate our own ideas we tend to notice and cite only those examples which support our claims and ignore those which do not. So any book, web site, or lecture which makes comparisons to Galileo or other such figures should be suspect in terms of the soundness of the reasoning and the intellectual honesty and humility of the author.

A lovely example of this is a book by a lawyer who often defends alternative medicine providers against government regulation, Richard Jaffe, who titled his own book about his work Galileo’s Lawyer.

2. The Dan Brown Gambit-

Despite some worrisome signs of growth and the lax oversight by government thanks to effective legislative lobbying, alternative medicine is a fairly small, largely marginal element of healthcare overall. It tends to serve primarily affluent clients with chronic complaints, often involving largely subjective symptoms such as pain or fatigue, and people with philosophical predilections towards it such as postmodernist liberals, some varieties of libertarians, and those generally suspicious of modernity, materialism, and methodological naturalism. Mainstream science-based medicine has earned the confidence of people by producing unequivocal results, it is generally preferred by most people unless they have one of these philosophical objections to it or a condition which science does not yet have clearly effective treatments for.

Unable to accept this fact, many CAM advocates argue that their methods are better but have failed to replace scientific medicine due to a conspiracy of suppression by the medical-industrial complex. A nice example of this comes from one of the more extreme alternative medicine sites, Shirley’s Wellness Café:

“Dr. Guylaine Lanctot, M.D. – The medical establishment works closely with the drug multinationals whose main objective is profits, and whose worst nightmare would be an epidemic of good health. Lots of drugs MUST be sold. In order to achieve this, anything goes: lies, fraud, and kickbacks. Doctors are the principal salespeople of the drug companies. They are rewarded with research grants, gifts, and lavish perks. The principal buyers are the public – from infants to the elderly – who MUST be thoroughly medicated and vaccinated…at any cost! Why do the authorities forbid alternative medicine? Because they are serving the industry, and the industry cannot make money with herbs, vitamins, and homeopathy. They cannot patent natural remedies. That is why they push synthetics. They control medicine, and that is why they are able to tell medical schools what they can and cannot teach. They have their own sets of laws, and they force people into them. That is a mafia. This sensational expose’ also uncovers the truth behind vaccines, AIDS, cancer, the World Health Organization, the Rockefeller Foundation, the World Bank, and more. Dr. Lanctot, M.D is the author of The Medical Mafia  How To Get Out of It Alive and Take Back Our Health and Wealth.”

These arguments resemble those found in many Dan Brown novels, in which thin threads of evidence are used to claim that venal cabals of robber barons collude with doctors to maintain people in a state of constant illness, despite the availability of cheap, natural cures for all diseases, solely because of their devotion to profit and power. This is closely related to both the Galileo Complex and what I have elsewhere called the David and Goliath Myth. As in most every other human endeavor, claims of shadowing conspiracies to silence the truth ought to be viewed skeptically, as they are often a cover for the simpler fact that vacuous and mistaken ideas fail to find acceptance because people simply aren’t fooled by them.

3. Deep Secrets-

Difficult to disentangle from the phenomena already cited is the slightly twist on the underlying theme I call Deep Secrets. Many advocates of alternative medicine will claim they have found simple and obvious knowledge that has been hidden from the rest of us, either by our own slavish acceptance of the propaganda of the Medical-Industrial Complex or because the secrets have been actively suppressed. A couple of examples of this are Dr. Andrew Jones book The Veterinary Secret, Kevin Trudeau’s Natural Cures “They” Don’t Want You to Know About, but there are many others. Claims of secret wisdom uncovered by lone geniuses and available to you free (as long as you buy their book, DVD, etc), should always raise one’s suspicions.

4. The One True Cause of All Disease-

Harriett Hall at Science-Based Medicine has written eloquently about this phenomenon. Many CAM proponents claim their method is based on understanding the “true underlying cause of disease,” while scientific medicine is merely treating symptoms. Most times, this “true cause” is some sort of perturbation of a vitalist energy detectable only by the intuition of the practitioner. While people prefer the simple and definitive to the complex and ambiguous, reality is under no obligation to conform to our wishes for it, and reality is often complex and ambiguous. If there were one simple and obvious true cause for all illness, I cannot imagine that it would not have been found and manipulated at some point in human history with such great success as to eliminate all disease and displace all other models of health and well-being. The failure of this to happen is one of the better bit of evidence against the claim. And I have wondered aloud before how CAM proponents rationalize the use of multiple therapies concurrently each of which is based on totally incompatible One True Causes of disease. A cause for doubt if ever there was one.

5. If It Sounds Too Good To Be True, It Is-

An old maxim, but a sound one. People will often investigate with a sharp, critical inquiry the details of a new electronics or automotive purchase looking for solid evidence on which to make a choice, and yet the same people will throw common sense and skepticism away when fed an appealing line of pseudoscientific sales patter by an alternative medicine advocate. Practitioners of scientific medicine are often at the public relations disadvantage of having to be truthful with our patients and clients, including admitting to the limitations of our knowledge an ability to solve their medical problems. Anyone who claims dramatic and unprecedented success with no risks should be pressed to produce more than their word or the testimonials of fellow believers to back up such claims, because such claims so often prove false in every area of human endeavor and medicine is no exception.

My recent brush with the “healthcare choice” concept, as well as a podcast interview I listened to with Dr. Paul Offit on Point of Inquiry put me in mind of an interesting and challenging puzzle in the philosophy of medical practice; the question of the tension between the role of health care providers as experts and the autonomy of patients of veterinary clients. I subsequently ran across an articulate and cogent discussion of this problem from the Annals of Internal Medicine, Physician Recommendations and Patient Autonomy: Finding a Balance between Physician Power and Patient Choice, which I highly recommend to anyone interested in understanding the complexities of the relationship between healthcare providers and patients.

Briefly, human medicine has traditionally followed the paternalistic model, in which the doctor is viewed as an expert with knowledge and skills the patient does not have. The doctor is expected to determine what is best for the patient and make the treatment decisions, which the patient is expected to accept. The disadvantages of this approach are obvious. As the authors of the article from the Annals put it, “it can be difficult to determine what a patient’s best interests are; inappropriate biases caused by sex, race and socioeconomic status can affect decision making; and patients can be deprived of the opportunity to make decisions that reflect the reality of their conditions.” The paternalistic model ultimate fails to give appropriate respect to the rights of patients to control their bodies and lives.

Many decisions made in the context of health care are not truly medical decisions so much as decisions about values. Quality of life, physical and emotional suffering, tolerance for risk, and many other factors affect the appropriateness of a given treatment plan that are subjective and truly accessible only to the patient. It is widely understood now that the paternalistic model is not ideal, and for at least 30 years most physicians have been trained in a more patient-centered model in which patient autonomy is properly valued.

What is less well-recognized, however, is that there are strengths and benefits associated with the paternalistic mindset. The reality is that despite the easy availability of large quantities of raw information, a deep and accurate understanding of medicine and the basic scientific principles underlying it is not readily available without the years of study and training health care providers undergo. The Internet has convinced us that we can quickly be experts in any area regardless of our personal abilities, skills, and experiences, but this is an illusion. Knowledge without understanding is dangerous because it leads us to confidently make poor decisions. The reality is that in the complex world of modern medicine even professional physicians can easily be overwhelmed by the required and ever-growing knowledge they need to make sound decisions, and lay people will only do poorer in judging the potential risks and benefits of particular interventions, no matter how much time they spend Googling the issue.

The alternative patient-centered or independent choice model of medicine has the obvious strength of giving proper respect to the autonomy of the patient and their feelings and values. However, in its extreme form it explicitly prohibits the doctor from offering recommendations or counsel, and limits the role of the provider to a neutral recitation of the statistical and technical features of various options among which the patient must choose entirely independently. This abdicates any responsibility for the welfare of the patient so long as autonomy is preserved.

There are some differences between human and veterinary medicine in how this tension between reliance on doctor expertise and authority and the autonomy of veterinary clients plays out. The paternalistic model was never fully realized in veterinary medicine due, in part, to the role of the animal patient in the lives of the clients. Traditionally dominated by agricultural applications, veterinary medical decision-making was long constrained by the need to focus on the utilitarian or economic value of the patient. Even non-agricultural animals were often viewed in a more utilitarian way than is now the rule, and the dominant model of companion animal medicine was not unlike that of auto mechanics. People would bring their dysfunctional pets to be repaired or, if this was not possible or the economic cost was too high, to be destroyed.

The profession has changed greatly, and now companion animal medicine is far larger a domain than agricultural practice, at least in terms of the number of veterinarians if not the total economic value of the industry. The prevailing model is much closer to that of pediatric human medicine than auto repair. Pets are commonly seen as individual family members, and the focus is on their health and well-being rather than their utility in most cases. Of course, economic limitations are still far more stringent than in human medicine, and the resources available are less, but very similar principles apply. The decisions made affect the patient directly, but the patient cannot themselves make decisions or even express their wishes. The interests of clients and patients sometimes conflict, and the veterinarian must attempt to serve both while maintaining acceptable professional and ethical standards and an economically viable practice.

The issues discussed in the Annals paper often arise in companion animal medicine. Many decisions, especially involving quality and end of life as well as economics, are value decisions rather than medical decisions, and so the autonomy and independence of the client must be respected. However, the doctor does have knowledge and understanding not available to most clients, and so ought to be able to offer guidance as well as factual information to assist in decision-making. What is more, the veterinarian has a duty to the patient, and protecting the patient’s interests sometimes requires working against the desires of the client.

How, then, do we negotiate the complexities of the veterinarian-patient-client relationship in a way that safeguards the interests of the patient, respects the values and autonomy of the client, makes optimal use of the expertise of the veterinarian, and is economically tenable for all parties? I cannot claim to have a comprehensive answer, but as always I have a  few thoughts.

To begin with, veterinarians should be trained to explicitly acknowledge the questions and issues involved. Very little time in vet school is spent discussing these concerns or how they might be addressed, and most veterinarians end up stumbling into an approach that seems to work for them with little or no guidance. As a consequence, practice styles range from those veterinarians who only discuss options they wish the client to pursue and who freely tell clients what they ought and ought not to do, to veterinarians who try to practice a strictly “independent choice” model and never make an explicit recommendation or voice any personal opinions in the consultation room. As is so often the case, the best solution seems to be between the extremes, and it is likely to be an ever-evolving, self-aware process rather than a rigidly fixed formula or algorithm.

The Annals paper discusses at length what the authors call the “enhanced autonomy” approach. Essentially, this involves trying to integrate the factual details of the medical situation with the values, feelings, and interests of the doctor and the patient through open and careful communication. While the patient must ultimately make the final decision about their own care, the doctor is not obligated to ignore the medical facts as they understand them, nor their own judgment. The authors describe the advantages of their model in this way:

“The independent choice model reflects a limited conceptualization of autonomy. Under this model, it is thought that an independent choice is best made with no external influence, even when one’s competence to make the choice is limited. However, autonomous medical choices are usually enhanced rather than undermined by the input and support of a well-informed physician. Only after a dialogue in which physician and patient aim to influence each other might the patient fully appreciate the medical possibilities…Enhancing patient autonomy requires that the physician engage in open dialogue, inform patients about therapeutic possibilities and their odds for success, explore both the patient’s values and their own, and then offer recommendations that consider both sets of values and experiences. This model is “relationship-centered”….rather than exclusively patient-centered. It denies neither the potential imbalance of power in the relationship nor the fact that some patients might be inappropriately manipulated or coerced by an overzealous physician. It assumes that an open dialogue, in which the physician frankly admits his or her biases, is ultimately a better protector of the patient’s right to autonomous choice than artificial neutrality would be. Because the biases of a physician will probably subtly infiltrate the conversation even if he or she tries hard to remain neutral, it may be better to explicitly label these values than to leave them outside of the conscious control of either participant.”

Such a model is well-suited to companion animal medicine as well. It requires first and foremost open acknowledgement of the roles both client and veterinarian play in making decisions for the patient. The veterinarian has knowledge and competence the client does not. They are able to appreciate the complexities of the medical situation, and they have the emotional objectivity to view potential outcomes realistically. The veterinarian also has a responsibility to advocate for the interests of the patient and to adhere to their own ethical and professional standards. Finally, the veterinarian has a fiduciary responsibility to the client.

The client has the ultimate responsibility for caring for their pet in a way consistent with their own values and resources. They understand the pet and their interests in a direct and personal way not available to the veterinarian. Therefore, the client must be the ultimate decision-maker regarding their pet’s care. However, part of their responsibility to the pet is to be aware of and attempt to compensate for the interference of their own interests with those of the pet. And as part of the duty to give the best care possible, the client should understand and acknowledge the need for the guidance the veterinarian can offer out of their deeper understanding of the medical questions at issue.

Interestingly, this model for the veterinary-client-patient relationship shares some features with the principles of evidence-based veterinary medicine. One widely used definition of EBVM, which I have cited before, is “the integration of the best research evidence available with clinical expertise as well as the unique needs or wishes of each client in clinical practice.” Balancing the best available information, which of course is primarily the province of the veterinarian, with the needs and wishes of the client requires both the client and the veterinarian to accept the limitations of their own knowledge. The client should defer in matters of medical fact to the veterinarian, who is in a better position to understand the medical issues in a deep and meaningful way. The veterinarian, in turn, should acknowledge the limitations of their own knowledge and experience and rely on the best and highest level evidence available to guide their recommendations. The doctor must also defer to the client in areas where the core issues are those of values rather than medicine, while of course still staying true to their own ethics and understanding of appropriate standards of care.

These negotiations between the interests and competencies of the parties involved are complex and situational, and they require explicit, clear communication, thoughtful self-reflection, and a willingness to consider and integrate factual information with sometimes contrary interests, values, and perspectives. This all makes the activity both difficult and sometimes frustrating and also richly rewarding.

CAM proponents often engage in the rhetorical fallacy known as special pleading. Wikipedia’s definition of this is adequate: “a form of spurious argumentation where a position in a dispute introduces favorable details or excludes unfavorable details by alleging a need to apply additional considerations without proper criticism of these considerations themselves. Essentially, this involves someone attempting to cite something as an exemption to a generally accepted rule, principle, etc. without justifying the exemption.”

Because many forms of CAM, such as homeopathy and various “energy” and “mind-body” therapies are based on principles inconsistent with established scientific knowledge, their advocates sometimes have to try and find ways to justify why these methods should be taken seriously despite this major weakness. They frequently argue that their methods rely on principles science does not yet, or perhaps cannot, understand. They argue that, despite the incontrovertible success in the last few hundred years of established methods of scientific investigation in figuring out and manipulating phenomena in the real world, these methods are culturally defined (i.e. “Western”) and only apply to their cultural of origin, or that they are incapable of dealing with new kind of phenomena.

These arguments seem pretty weak in the face of historical reality, but there is of course always a chance that a given “paradigm shift” or “revolutionary” new principle of biology, medicine, or physics has been discovered that turns all we know out the door.  However, this is an extraordinary claim, and it cannot be defended simply by pointing to a few anecdotes, one’s personal experience, or the ultimate foundation I believe it really rests on, faith. The whole reason we even have a category of medicine called “alternative” (or as I prefer to call it, “faith-based medicine”) is because people believe things they cannot convincingly demonstrate to those who do not share their faith or their trust in personal experience.

In 2008, there was a symposium held at the UCLA Center for East West Medicine (note the postmodernist bias that all knowledge is culturally relative even in the very name of the organization) and reported in eCAM. The purpose of the symposium was, as always, to try and convince mainstream medicine and the public of the scientific legitimacy of CAM.

“Its purpose was to address the finding by the National Center for Complementary and Alternative Medicine (NCCAM) that IRB’s may be unfamiliar and/or uncomfortable with unconventional medical modalities thus apt to disapprove studies of those modalities. The hope was to better this state of affairs by familiarizing the audience with some of the major controversies surrounding CAIM research and its regulation.”

NCCAM has been widely criticized for being a tool of the CAM political lobby and of wasting taxpayer money trying to validate implausible therapies only because they are favored by powerful politicians or well-funded lobbies. This criticism, and questions about the scientific legitimacy and ethics of NCCAM-funded research was raised by critics at the UCLA symposium, and the responses of CAM advocates are enlightening in that they demonstrate the special pleading CAM requires because it cannot meet the evidentiary standards of scientific medicine.

According to the eCAM article, “Dr Ary Goldberger, Director of the Margret & H. A. Rey Institute for Nonlinear Dynamics in Medicine at Boston’s Beth Israel Deaconess Medical Center and Professor of Medicine at Harvard Medical School….suggested that conservatism in science extends to the underlying approach to physiological systems, often wrongly privileging homeostasis (‘constancy as the wisdom of the body’) over complex adaptability, multi-scale dynamics and emergent properties. In as much as they are non-linear, non-stationary, non-additive and show time irreversibility, however, complex systems may be inaccessible to conventional analytic techniques, according to the speaker. Dr Goldberger left the impression that he believes both investigators and NIH Centers in general ought to be more open to novel but rigorous research designs and methodology.”

So here’s the claim that because CAM methods don’t seem to get validated by conventional scientific investigations, the flaw must be not with those methods but with the very nature of science. We need to invent new ways of studying nature, despite the wild success of our current approach, because the methods he favors don’t get validated the way we do things now. Again, paradigm shifts do happen, but they are rare, and the vast majority of revolutions proclaimed by outsiders in science are nothing more than desperate attempts to defend failed ideas.

Next, Distinguished Professor Edwin Cooper (Editor in Chief, Evidence Based Complementary and Alternative Medicine) “raised questions about what passes for good research methodology, asking whether studying ancient, whole systems of medicine using Western, reductionistic techniques doesn’t strip them of essential features.”

Here again is the postmodernist notion that truth is culturally relative, and that science somehow only applies to ideas that originated in the culture that most directly contributed to the creation of modern scientific methods. This is blatantly ridiculous, as any Chinese or Indian or other “Eastern” patient benefiting from modern scientific medicine could tell you. Our physiology doesn’t care where we live or what language we speak, physics doesn’t work differently on different continents, and while values depend heavily on culture, the truth about how our bodies work doesn’t. Millennia of traditional folk methods in India or China or anywhere else failed to eradicate infectious diseases like polio, lower infant mortality, raise life average expectancy, or otherwise improve human health and well-being to anything like the extent “Western” science has in only a few hundred years. The notion that other cultures have other medical realities is at best a sincere but weak defense of implausible or outright failed ideas based on the inappropriate translation of cultural relativism to the scientific domain. At worst, it is simply old-fashioned orientalism with the patina of scientific “open-mindedness.”

My favorite comment, though, comes from Professor-in-Residence Mark Cohen. First continuing the special pleading approach, he “expressed the view that current research tools may be inadequate for measuring the effects of some CAIM treatments.” Yeah, well prove it. But he then went on to all but admit that CAM is a faith-based belief system much more like religion than science: “he noted that taxpayers already support faith-based initiatives and questioned whether conventional science has a ‘special entitlement’ to public funds, given that orientation.” Here he is saying that because a large number of Americans accept giving government money to religious organizations for performing services previously considered the responsibility of a secular government, we should similarly support giving taxpayer dollars to study CAM rather pretending conventional science should have a special claim to research money just because it is a proven and effective approach and CAM is mostly a hodgepodge of vitalism, folk traditions, and stuff outright made up by unappreciated lone genius or know charlatans. Our faith, our belief alone should be sufficient to justify it. It isn’t possible to be much clearer about the philosophy behind alternative medicine than that.