Treating the parts that real medicines cannot treat – a place for placebos

As a skeptic I have a shameful confession to make: I once had an imaginary condition miraculously cured by a placebo treatment.

Some conditions have symptons but not signs. Symptoms are felt and reported by patients, signs can be detected using some form of test. Headache and nausea are symptoms of migraine, vomiting and pallor are signs.

About 10 years ago I went through some high-stakes changes and made a career-move which required full-on keyboard use.  But I developed Repetitive Strain Injury which affected my hands to the extent that I experienced pain up to my shoulders.  Lawyers have a field day with RSI, because some repetitive strain injuries such as Carpel Tunnel Syndrome have signs, but others are just painful with no measurable physical changes. The long and the short of my story is that I bought a wrist magnet and strapped it on my right arm. Within half an hour my right arm was considerably less painful than my left and over the next few days the pains disappeared completely. I was able to take up my new job with no problem at all.  A miracle cure! For a condition my doctor had been powerless to treat! Woo hoo!

Doctors are often exasperated by patients who turn up with functional conditions (ie ones which have symptoms but not signs) because there is nothing concrete to treat and no objective way to measure outcomes. In the worst case, they consider the patient to be a malingerer and even in good cases trust between paient and doctor break down and create a space for kindly Alternative Medical practitioners to step into. Functional conditions are for Alt Med of course because the intervention needed isn’t medical. It’s in the realm that Terry Pratchett’s Granny Weatherwax calls “headology”. The wrist magnet really did cure my RSI.  It worked, not because it improved the flow of fluids in my body, but because I thought it improved the flow of fluids in my body.

Placebos are a side-effect free way to treat conditions which can’t be treated using evidence-based medicine. Let’s be clear here: these conditions are honestly experienced by people of integrity. Just because their minds and bodies are lying to them, doesn’t mean they are lying to the doctors. But there are no symptoms that can be measured and treated so the medical model and the patients’ experience simply don’t overlap. This creates a gap in the market which alt med happily and sometimes effectively fills. But not all alt med is innocent and all of it is expensive and based on false models and premises. We need medical science to admit there is something going on here that needs treating, rather than dismissing functional conditions as hysterical, imaginary or psychosomatic.

Unfortunately, medics who accept that placebos may indeed be appropriate for these conditions cannot bridge gap by prescribing them, even if they will work where “real” treatments fail. Doctors consider it unethical to lie to patients, and I think most patients would agree with them. So at the moment there is indeed a place for alt med in providing these interventions.  Alt Med has no place in treating pathological conditions of course (ie “real” ones): flower drops and sugar pills cannot treat cancer, and magnetic bracelets can’t cure Carpel Tunnel Syndrome.

TAM London – How should Skeptics debate?

One of the strands at this year’s #TAMlondon was the question of how strident should skeptics be? Tim Minchin referred to this as the question of tone.

P Z Myers argued (calmly, kindly, almost sweetly) for anger, ridicule and truth. D J Grothe by contrast put it to us that we should be both rationalists and humanists, that we have to be good about being right, because being right by itself is not enough. Melinda Gebbie reminded us that one of the sources of failure in the feminist movement was that “didn’t have a maniesto of behaviour”, in other words because too many of them were self-indulgent and became whiny, strident and easily ignorable caricatures.

This disagreement is no surprise: Richard Wiseman (I think) reminded us that when cats get frustrated they talk about herding skeptics. That’s what happens when you have a bunch of people who think for themselves.

I’m with D J Grothe on this one, though. I think the key to how we interact with others (even the dull and ignorant) is respect.   As one of the TAMsters asked P Z Myers

Is it constructive to be so confrontational?

Why the different approaches? What do we want to achieve when we engage with the purveyors of woo? Randi told Robin Ince that he is fuelled in part by anger and wants to expose the liars and shut down the frauds. His motivation for exposing “faith” healers was rage; rage at the shamless way they turned grief and fear, and disability into cold hard cash. Dawkins is angry about the abuses of human rights embedded in Sharia law’s treatment of gays and of women. Evan Harris is disgusted that Boots’ excuse for duping the ill with homoeopathic remedies is that they are also available on the NHS.  There is indeed a lot of anger among skeptics.

However, I suspect that others who claim to be fuelled by anger are just fuelled by the need to be Right. That it’s egotism, pure and simple, and a bullying egotism at that.  One interesting quote from Myers was

“We have science and reason on our side”.

Well, surely it should be the other way round? Shouldn’t we be on the side of science and reason? One of the unexpected highlights for me was Susan Blackmore’s account of her double-blinded, randomised, statistially significant journey from woo to material atheism as she researched for decades but found no evidence for the psychic powers she absolutely believed in.

Back to the question of how should we debate? Too often, exasperated passion comes across as shrillness and underemines the message.  Debates between skeptics and believers frequently collapse in a morass of crossed purposes based on different ways of testing and arriving at the truth. Did Tim Minchin persuade Storm that she was narrow minded and wrong, or merely shout the poor woman down?  Both P Z Myers and Adam Rutherford reminded us: “Don’t be a Dick”.

The success or failure of these debates so often boils down to what kind of knowledge the debaters accept as true. Assertions that my logic is better than your intution are pointless.  Stupidly so. Our double blinded randomised controlled trial does NOT beat their personal experiences (in their minds at least), no matter how much it convinces intelligent, empirical, skeptical us.  Besides which, it is always so much more interesting to find out WHY people think what they think than to listen to yourself prating on about evidence to somone whose touchstone is their intuition.

So do you assume you are dealing with charlatans? Or with fools? Or with people of intelligence and integrity whose approach to uncertainty and evidence are different from yours? And this last one is, of course, much more threatening than the dismissive thought that “they’re all stupid”.

And how do your assumptions colour your debate?

(More on TAM London soon).

An atheist’s guide to wrestling pigs

Richard Bandler, one of the co-founders of NLP, points out rather smugly that the word “generalisation” is just five syllables wrapped around the word “lies”. We all know that generalisations are false, but still we make them. What bugs me immensely about atheists who are anti-religion, rather than those who are just indifferent, is their tendency to see all christians as prejudiced zealots. Takes one to know one, of course. No projection there.

The thing is, there are as many kinds of Christians as there are kinds of people. Yes, some are bigoted, narrow-minded and spiteful, but not all. Not all, at all. There is a specific kind of Christian that I find compelling and attractive; the ones who are intelligent and questioning, funny, socially sensitive, tolerant of others and who quietly get on with making surprisingly substantial changes in the world. I’ve known rather a lot of them and I’d quite like to be one myself. In my dreams. They put me into a cognitive spin because I find the whole premise of Christianity so illogical that I simply don’t understand how anyone with two brain cells and a synapse can find it makes sense. How can anyone so bright be so dumb, I ask myself. They probably feel the same way about me.

When rabid anti-religionists start attacking Christians, I don’t recognise the form of Christianity they attack. I’ve known a few creationists, fundamentalists and people who have a personal relationship with their saviour and lord, and the internet constantly reminds me that they aren’t actually that unusual. I guess in the UK we are blessed with agnosticism and are spared the lunatic excesses of religious tv, evangelism and fundamentalism. I once visited the Bible Society head office in Swindon, though; it was like walking through a toothpaste advertisement made in Stepford.

They say you should never wrestle with a pig: you get muddy and the pig likes it. Put like that, it sounds kinda fun. And that’s the problem. The best responses to bigoted fundamentalists are ridicule and education, and the best responses to powerful bigoted fundamentalists (like the lunatics who’ve been running the asylum in the USA for the last years) are still ridicule and education. But in the US the Scepticism and Sceptical Humanism movements are getting sucked in to point-scoring and pig-wrestling, when it should in fact be poking fun at the pig. And then ambling off and doing something more interesting instead.

Farewell to flakiness – or why I’m not entitled to my own opinion

I was raised by people of great personal and moral integrity with reasonable intelligence who had no exposure to science or scientific thinking at all. This didn’t stop them having Opinions on things so it is no surprise that they were Flakes one and all. Bless ’em.

Flaky thinking is cozy, it provides comfort blankies such as “everything happens for a reason”or “someone was looking after me that night”. It also provides explanations which appear to be simple and easy to understand: ” stimulating the body’s natural healing processes” or “bright lines of golden energy”.

I’m not going to rip into acupuncture, auric photography, biomagnetic bracelets, biorhythm charts, cranial-sacral therapy, earth energy lines, feng shui, food sensitivity analysis, homoeopathy, osteopathy, reiki or any of the other forms of flakiness which I’ve spent money on in my time. To be honest, I cannot be bothered. Either you consider me to be foolishly narrow-minded because I dismiss them or foolishly forebearing because I don’t critique them and we both have better things to do with our time than argue the point.

Let’s just say that I spent my money on all of the above, probably thousands of pounds now that I look at the list, but I don’t feel ripped off; every one of them brought me a good 40 minutes of someone’s undivided attention and a nice warm placebo effect. I was lucky; it was a life-style choice not a fearful attempt to ward off cancer. But I wouldn’t spend my money on any of them again.

So what undermined my warm fuzzy view that the word “energy” means something when used metaphorically, that there are forces which cannot be measured by science, and that there is more to life than meets the eye?

Lots of things. Feel free to skip the list and cut to the conclusions at the end of the piece.

• I check out the Asthma UK site and realise the approaches described are infinitely more cautious, detailed, rigorous and robust than the approaches of the herbalists I’d instinctively turn to.
• My father, with cancer, is dramatically better after a stay in hospital which grants him at least another year of good quality of life.
• A crystal healer describes the “lovely warm lines of yellow energy” flowing through her treatment rooms. When I ask her if she can see them she says “no, but Gordon has dowsed them and told me where they are”. The inane warmth in her voice sets my alarm bells ringing.
• I read The Selfish Gene by Richard Dawkins.
• I have to describe my symptoms to the German pharmacist rather than selecting the herbal tinctures and ointments I’d choose in the UK; I find myself thinking “These German pharmaceuticals are very effective” and then realising that they might work well simply because they are pharmaceuticals and being German has nothing to do with it.
• I work for a large petro-chemical company and find that the individuals there are responsible and serious people, and not in fact the spawn of satan who just don’t “get” it.
• I acknowledge that the scientists working on GMOs are (a) intelligent and (b) not malicious. I think that they are wrong about genetically modified organisms being good for the planet, but acknowledge that if they are wrong then it’s not because they are stupid.
• A friend sends me a link to DHMO.org and I realise just how easy it is to writes spurious science-speak which is manipulative and emotional.
• A friend of mine compulsively adds and subtracts numbers to find co-incidences and meanings without noticing that if you manipulate any date enough you can reach the number 7, or 26.
• I read something which explains that the phenomena described in all documented near-death experiences (tunnel vision, a distant light, etc) are also consistent with specific forms of neurological shut-down.
• I develop an increasing respect for the methodologies in my own field, and by extension for standards’ based methodological approaches in others. In other words, I come to prefer rigorous testing to instinct.
• I have a relationship with a statistician.
• I come across evidence that a feeling that there a ghostly presence in the room can be reliably triggered by certain localised electro-magnetic phenomenon.
• I read The Demon Haunted World by Carl Sagan.
• I regularly flick through copies of the British Medical Journal and discover that the research studies are of varying quality but explicit about their limitations and scope.
• Triptanes provide effective migraine relief.
• I read Snake Oil by John Diamond.
• I start a post-grad degree and within a few months become imensely more picky about authorities and references.

Ok. It’s not a particularly impressive list: a lot of it is based on a distaste for poor critical thinking in others which of course doesn’t demonstrate any improvement in my own, the books are pop-science even if the scientists are credible, the rest of it is un-referenced and at this distance in time I have no way of checking where I got the information about near death experiences and ghostly presences from.

But…

But I think that the real epiphany is that I am only entitled to an opinion on subjects where I have some expertise. Guess what – experts really do know better. It’s a matter of knowing my limitations. I cannot bake cakes, design power stations or diagnose illnesses. I have no choice but to delegate those tasks. Generic intelligence is not the same as experience, training or qualifications and this is hard for people, particularly those educated in the social sciences or humanities, to accept.

Not all experts are equal, of course. Gillian McKeith’s “doctorate” is a tad light-weight to say the least, though the woman is undoubtedly sincere. We cannot accept the word of experts unquestioningly. We must continue to challenge and ask the pertinent questions – how did you arrive at that conclusion – how large was your sample-size – how well conducted has your research been – where do you get your funding, and so on. But challenging does work: 20 years of hindsight bias, selective memory, anecdotal evidence and the placebo effect do not equal one double blind controlled trial. Sorry.

Some people argue that science is just as much a matter of belief as religion is. It isn’t of course. I’ve argued that you have to trust the scientists but as Reagan put it you “trust but verify”. You can by definition repeat and test a scientific experiment or demonstration. You cannot test bach flower remedies, post-modernism or god. In fact there’s even a commandment against it.

This of course means that the opinions of true experts whose conclusions are based on testable and repeatable methods vastly outweigh yours and mine. We are entitled to doubts, concerns, worries, uncertainties and even rage, anger and disgust. Those are emotions and emotions are not opinions. We must also remain entitled to challenge – that is what accountability is.

To some extent I do miss the warm fuzziness of flaky thinking, but on the other hand if you acknowledge that real life is unfair, that shit happens, it becomes much easier to deal with. Nastier, but more straight-forward. There are a few flaky things I still adhere to: meditation, NLP and yoga specifically, though I’m not going to defend them here. The only school of “alternative” thought which I have not yet found to be intellectually undermined is the Buddhist approach to re-incarnation. To be honest, I doubt it’s got any validity to it, but does have the merits of being (a) internally consistent and (b) not yet countered by harsh scientific enquiry. However you look at it, the idea that bad things happen to good people for no reason is a nasty one.

I had been going to illustrate this with one of the Cadbury’s Flake ads but I couldn’t find the girl painting a picture in a poppy field in the rain, so I decided to show you this instead which did at least make me laugh.