NonEvidenceBased Medicine Medical Ethics and Medical Quackery Kevin

Non-Evidence-Based Medicine Medical Ethics and Medical Quackery Kevin T. Keith Skepticamp NYC 12/3/2011

Skepticism “Modern skepticism is embodied in the scientific method, which involves gathering data to formulate and test naturalistic explanations for natural phenomena. ” — Michael Shermer, Why People Believe Weird Things “Skepticism, a form of evidence-based reasoning, is a way of knowing that weighs evidence and prior plausibility in determining if a claim is true. . Learning how to foster a skeptical outlook can make it less likely that a person will be scammed by fraudsters or fall for unproven or non-evidencebased pseudoscience, scientific or historical denialism, and supernaturalism. ” — Jeremy Salow, “What is Skepticism” Non-Evidence-Based Medicine 1 Kevin T. Keith

Skepticism, Beliefs, and Values “The greater the ignorance, the greater the dogmatism. ” — William Osler, “Chauvinism in Medicine” “The skeptic, being a lover of his kind, desires to cure by speech, as best he can, the self-conceit and rashness of the dogmatists. ” — Sextus Empiricus, Outlines of Pyrrhonism “All of these definitions [of skepticism] describe a process, not a conclusion. They describe a search for truth, not a search for values. In fact, there is a clear and very scientific statement that values are irrelevant: ‘A skeptic is someone who applies vigorous and systematic research to any claim, regardless of its political, religious, or social implications. ’. . . What’s more, the promotion of values cannot be included in this pursuit. ” — Barbara Drescher, “Scientific Skepticism: A Tutorial” “I would defend the liberty of consenting adult creationists to practice whatever intellectual perversions they like in the privacy of their own homes, but it is also necessary to protect the young and innocent. ” — Arthur C. Clarke, 1984: Spring, A Choice of Futures Non-Evidence-Based Medicine 2 Kevin T. Keith

Medicine and Medical Science “Like everything else that is good and durable in this world, modern medicine is the product of the Greek intellect, and had its origin when that wonderful people created positive or rational science, and no small credit is due to the physicians who. . . very early brought to bear the spirit of criticism on the arbitrary and superstitious views of the phenomena of life. . The critical sense and skeptical attitude of the Hippocratic school laid the foundations of modern medicine on broad lines, and we owe to it: first, the emancipation of medicine from the shackles of priestcraft and of caste; secondly, the conception of medicine as an art based on accurate observation, and as a science, and integral part of the science of man and of nature; thirdly, the high moral ideals, expressed in. . . the Hippocratic oath; and fourthly, the conceptualization and realization of medicine as the profession of a cultured gentleman. ” — William Osler, “Chauvinism in Medicine”, 1902 “A physician shall continue to study, apply, and advance scientific knowledge, maintain a commitment to medical education, [and] make relevant information available to patients, colleagues, and the public. . ” — American Medical Association, “Principles of Medical Ethics” Non-Evidence-Based Medicine 3 Kevin T. Keith

Skepticism and Medicine “Quackery [is defined] as the promotion of unsubstantiated methods that lack a scientifically plausible rationale. ” — Stephen Barrett, MD, “Quackery: How Should It Be Defined? ” “[There are] (a) several potentially beneficial features of homeopathy, including non-invasiveness, cost-effectiveness, holism, placebo benefits and agent autonomy; and (b) several potentially negative features of homeopathy, including failure to seek effective healthcare, wastage of resources, promulgation of false beliefs and a weakening of commitment to scientific medicine. A utilitarian analysis of the utilities and disutilities leads to the conclusion that homeopathy is ethically unacceptable and ought to be actively rejected by healthcare professionals. ” — Kevin Smith, “Against Homeopathy – A Utilitarian Perspective” Non-Evidence-Based Medicine 4 Kevin T. Keith

Skepticism and Medical Ethics “There is a fundamental obligation to ensure that patients have the right to choose, as well as the right to accept or to decline information. Forced information, forced choice, and evasive disclosure are inconsistent with this obligation. . To respect an autonomous agent is, at a minimum, to acknowledge that person’s right to hold views, to make choices, and to take actions based on personal values and beliefs. ” — Beauchamp & Childress, Principles of Biomedical Ethics “The use of unproven therapies is of concern for a number of reasons, including the lack of scientific evidence to support them, their potential financial costs and the possibility of interference with conventional treatment. . Health professionals involved in the care of cancer patients should be prepared to discuss the use of unproven therapies and try to identify and deal with unmet needs to help patients to cope with their illness. ” — Miller, et al, “The Use of Unproven Methods of Treatment by Cancer Patients” Non-Evidence-Based Medicine 5 Kevin T. Keith

Observations: Skepticism and Medicine • Skepticism rightly emphasizes scientific knowledge and methodology. • Medicine is grounded in science, and there is a natural correlation between the skeptical mindset and medical decision-making. • False claims about scientific matters can be confidently rejected by scientific methodology; the skeptical mindset encourages this. • Healthcare decisions based on false information can be criticized on epistemological grounds; medical knowledge and the skeptical mindset encourage this. • Science exists to promote defensible knowledge. Medicine exists to promote health as understood in light of the patient’s values and needs. • Not all healthcare decision-making hinges on scientific or epistemological question. Patient values do not have to reflect a skeptical mindset. Non-Evidence-Based Medicine 6 Kevin T. Keith

Case 1: Refusal of Proven Treatments Case 1(a): An adult patient is seen in an emergency room, bleeding severely. Blood transfusion is recommended. The patient refuses, citing religious beliefs that such a treatment is prohibited by God. Case 1(b): A young child is seen in an emergency room, bleeding severely. Blood transfusion is recommended. The child’s parents refuse, citing religious beliefs that such a treatment is prohibited by God. Case 1(c): An adult who has never been vaccinated for measles is advised to be vaccinated as a precaution. The patient refuses, citing beliefs that vaccinations are useless or harmful. Case 1(d): An child who has never been vaccinated for measles is advised to be vaccinated as a precaution. The child’s parents refuse, citing beliefs that vaccinations are useless or harmful. Non-Evidence-Based Medicine 7 Kevin T. Keith

Case 2: Choice of Unproven Treatments Case 2(a): An adult patient with cancer, who has access to advanced scientifically-based care, acquires an untested medicine from a foreign country and uses it against medical advice, in place of standard treatments. Case 2(b): An adult patient with cancer, who has access to advanced scientifically-based care, acquires an untested medicine from a foreign country and uses it against medical advice, in addition to standard treatments. Case 2(c): An adult patient with cancer, who has been denied advanced scientifically-based care on grounds of futility, travels to a foreign country to employ an “experimental” remedy with no demonstrated probability of cure. Case 2(d): An adult patient with cancer, who has been denied advanced scientifically-based care on grounds of futility, travels to a foreign country to employ an “experimental” remedy with no demonstrated probability of cure and which has been promoted as a “miracle cure”. Non-Evidence-Based Medicine 8 Kevin T. Keith

Case 3: Choice of Futile Treatments Case 3(a): A patient with advanced cancer demands aggressive treatment that has no known likelihood of curing the condition. Treatment will be expensive and debilitating. Case 3(b): A patient in a persistent vegetative state is dependent on ventilator support and other advanced care. The patient has no advance directive regarding such a condition. The patient’s family believes he will recover and demands continued treatment indefinitely; the hospital invokes a “futility” policy to discontinue treatment that cannot benefit the patient. Case 3(c): A patient in a persistent vegetative state is dependent on ventilator support and other advanced care. The patient has no advance directive covering such a condition. The patient’s family believes God will grant a miracle and demands continued treatment indefinitely; the hospital invokes a “futility” policy to discontinue treatment that cannot benefit the patient. Non-Evidence-Based Medicine 9 Kevin T. Keith

Case 4: Choice of “Paradoxical” Treatments Case 4(a): A healthy patient requests elective surgery to remove a normal finger (body modification) because it is “not really part of me”. Case 4(b): A patient with a developmental abnormality is advised to undergo corrective surgery but refuses, because the abnormal body part is “part of who I am”. Case 4(c): A patient with a treatable but potentially fatal condition refuses a treatment that has a proven high probability of cure, because the patient is convinced it will not work. Case 4(d): A patient with a treatable but potentially fatal condition refuses a treatment that has a proven high probability of cure, because the patient, although mentally competent, is depressed and convinced nothing will work. Non-Evidence-Based Medicine 10 Kevin T. Keith

Observations: Knowledge and Values • Skepticism demands stringent review of factual claims and empirical outcomes. This is of great value in the medical setting. • It is often possible to determine the likelihood of particular outcomes, or relative efficacy of different treatments, using scientific methods. • Patients’ preferences and decisions are not always based on simple questions of comparative efficacy. • It is widely agreed that patient autonomy includes the right to make unusual or idiosyncratic decisions; most skeptics do not dispute this. Patients may even rely on non-rational values or beliefs. • There is a limit to how far we will indulge patients’ preferences, however (cost, harm to others, questionable competency). • Skepticism itself does not always provide guidance on resolving marginal cases. Non-Evidence-Based Medicine 11 Kevin T. Keith

Citations American Medical Association, “Principles of Medical Ethics” (rev. 2001) http: //www. ama-assn. org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/principles-medical-ethics. page [12/1/2011] Barrett, Stephen, MD, “Quackery: How Should It Be Defined? ”, Quackwatch, http: //www. quackwatch. com/01 Quackery. Related. Topics/quackdef. html [reverified 12/2/2011] Beauchamp, Tom L. and Childress, James F. , Principles of Biomedical Ethics, 5 th Ed. , Oxford University Press, 2001, p. 63 Drescher, Barbara, “Scientific Skepticism: A Tutorial”, ICBS Everywhere, http: //icbseverywhere. com/blog/2010/04/scientific-skepticism-a-tutorial/ [reverified 12/1/2011] Megan Miller, M. J. Boyer, Phyllis N. Butow, Melina Gattellari, Stewart M. Dunn and Annabel Childs, “The use of unproven methods of treatment by cancer patients: Frequency, expectations and cost”, Supportive Care in Cancer, Volume 6, Number 4, 337 -347, DOI: 10. 1007/s 005200050175 Salow, Jeremy, “What is Skepticism: Evidence Based Critical Reasoning”, Philosophy, Suite 101, http: //jeremy-salow. suite 101. com/what-is-skepticism-a 95857 [reverified 12/1/2011] Sextus Empiricus, Outlines of Pyrrhonism, Book 3 Shermer, Michael, Why People Believe Weird Things: Pseudoscience, Superstition, and Other Confusions of Our Time , Holt Paperbacks, 2002, p. 16 Smith, Kevin, “Against Homeopathy – A Utilitarian Perspective”, Bioethics, 14 Feb, 2011, doi: 10. 1111/j. 14678519. 2010. 01876. x. [Epub ahead of print] Osler, William, “Chauvinism in Medicine”, The Canadian Practitioner and Review, v. XXVII, 1902, pp. 552 – 68 Non-Evidence-Based Medicine 12 Kevin T. Keith

Non-Evidence-Based Medicine Medical Ethics and Medical Quackery Kevin T. Keith ktkeith@ktkeith. com www. sufficientscruples. com @KTKeith Non-Evidence-Based Medicine 13 Kevin T. Keith