(From Science Based Medicine) Forks in the road
It’s been decades since the onslaught of organized quackery began against science and reason. Although most physicians are still capable of reasoning, the percentage of medical graduates whose brains have been cleansed of that ability seems to have increased. Either the brains have been cleansed or they have learned to coexist with unreason and to use both functions simultaneously. The latter is quite an accomplishment and is a testament to the flexibility and fluidity of the human mind (shorthand for brain function.) Psychologists have names for that function such as compartmentalization, rationalization, denial, heuristic maintenance, and cognitive dissonance.
Physician advocates of quackery are particularly unsettling because they seem to be so rational at times and appear so to the press and the public. Even more unsettling to me are the medical school department heads and deans and others who loosen the restrictions on the irrational so that peaceful coexistence and polite tolerance seem to be the preferred mode of mental existence in faculties. The NCCAM’s example needs no introduction.
Thus the matter-of-fact tone in which was reported an article in this week’s JAMA. As reported in our local papers, the headlines read: “St. John’s Wort fails to help kids with ADHD [Attention Deficit-Hyperactivity Disorder] in study.” That stopped me for more than one reason. First, any headline about a sectarian or implausible claim is a stopper. But second, StJW for ADHD? I’d never seen the claim. But the article explained that the author felt such a trial was worth doing because someone else had found that StJW increased the level of nor-epinephrine-like compounds in rat brains, so that perhaps St JW would work instead of stimulants for hyperactivity.
Makes some sense, right? But it is in fact a long jump. A reason was given by an interviewed mother of a patient, claiming to fear pharmaceuticals so much, she denied them to her ADHD daughter. So the ostensible reason for studying StJW for ADHD was to find a substitute for a purified, regulated pharmaceutical - an unrefined, uncontrolled, unpredictable plant extract. Just what positive social or medical advance does one call that? Perhaps there is a purifed isolate one might obtain from StJW? StJW has been tested in a number of other conditions and situations and found inactive, but with dangerous drug interactions. What IRB had the nerve to approve such a trial? Apparently those questions need not be answered if the NCCAM gives its assent.
Second, there was a small but definite chance the study could have come out positive by chance, or more likely, because of unreported variations in execution. The consequence would have been a series of confirming or disconfirming RCTs that would take 5-10 years and millions of dollars to resolve in the minds of real clinicians, and moreover, if negative would not alter the practices of either the public or naturopaths.
A further reading showed that the first author, described as “of Bastyr University’s School of Naturopathic Medicine, working with colleagues from Harvard University and the University of Washington…“ brought up the previously noted cooperation of UW with its neighbor, Bastyr U. The cooperation has been going on for years, and has resulted in some realistic clinical trials, one of which was a negative trial on Echinacea for prevention of colds in children.
Naturopaths have been consultants for the UW bone marrow transplant and oncology units also for a decade or more. As one Bastyr N’path explained to me on a visit here, N’paths are experts in natural substances and can help MDs to retain confidence of patients who are exploring alternatives, and who interpret words like “it doesn’t work” as personal rejection. N’paths, he said, can also serve as credible authorities in warning patients away from dangerous substances. I wondered aloud if Npaths were capable of warning people about dangerous practices - such as going to naturopaths.
Back to the report, a medical school cooperating with a naturopathic school? Good? Bad? Productive? Suspicious? Are the questions relevant? In a way the cooperation is all of the above, but with differing weights attached to each adjective. One thing is obvious. There is more to be gained by Bastyr than by UW from an alliance. Bastyr naturopaths have not to my knowledge published anything of consequence on their own. The alliance confers respect, allowing N’paths to break into the medical journal system, to build bibliographies, to publish enough credible studies to enable future federal grants, and eventually to obtain hospital privileges and expanded scopes of practice. About that can there be any doubt?
In reality, N’paths hold no fund of knowledge not available to MDs and other medical practitioners. At the same time, N’paths warp that knowledge’s application to fit ideological frames containing life forces, anti-technology, anti-public health measures and irrational fears of progress. Worse, N’paths believe a mass of unproved and false information that they claim as their exclusive area of expertise and which they apply on the basis of hunches and feelings. A N’path supplies no additional positive substance to healing the sick or to the science of medicine. In this sense, UW is an enabler of quackery, even if the short run product for the university could be algebraically positive. The overriding social consequence of enabling quackery, which is taught to Npathy students, is to spread a system of pseudo- and anti-science throughout the society.
One must grant the UW some degree of understanding for taking on this alliance, out of ignorance, innocense, and misplaced beneficense, but the establishing of precedent is an act they will one day regret and will find progressively more difficult to reverse. Bastyr’s existence and UW’s acceptance materialized in a social environment lacking an overarching theory of scientific social beneficence and a sense that something is wrong with anti-science.
Teaching a scientific ethic and philosophy begins with education in our pre-college schools, and continues with magnified importance in universities, which unfortunately have been taken over by political ideologues who teach ethical relativism and who belittle rationality, realism, and science. Medical schools are in a time of crucial transition and choice; to track into the new science of cellular and molecular biology while holding to and teaching classical traditions of reasoning, or to take the baited hook of social determinism and relativism, to an uncertain fate - likely to be as just another dish on the table.