Monday, October 25, 2010

Dr. Steve Novella responds

Excellent response by Dr. Steve Novella to my paternalism in science-based medicine posts. He does such a great job cherry-picking my arguments that he finally concludes "Zilberberg’s position is anti-science, although perhaps not deliberately so".

But this is my favorite quote, the final paragraph of the post (emphasis mine):
One final note – I would much prefer to have a conversation with the critics of science-based medicine that does not constantly involve defending SBM and myself from false accusations of arrogance and paternalism. I think it says a lot about their intellectual position when that is constantly the best they have.
If the shoe fits?

But seriously, he does make some interesting points. He oversimplifies a lot of the science (HTE is really not "medical student stuff"), and, while admittedly not straightforward, absence of evidence difference from evidence of absence is important to understand.

Anyhow, I am eager for my readers to go and read this response and continue this discussion. Let us keep it civil and informative. In the end, it is possible that we may come to some mutual understanding, no?  


  1. How is this continuing the discussion? You just pat yourself on the back for calling him paternalistic, say he cherry-picks your arguments (not sure how that’s possible when responding to such a short blog) and indirectly claim he doesn't understand you. You never address his main point that all medicine should be considered equally.

    If the basic science is implausible and trials repeatedly show no effect, do you agree that the procedure can be considered completely invalid? In the case of (like with reiki) the basic science is so implausible, would you agree that doing trials would only muddle the issue? And be a waste of public funds?

  2. It is about time someone stood up to these bullies!

  3. Dr. Zillerberg I appreciate your desire to be open minded, however, if I come to you as my physician and indicated that I would be using homeopathy and reike therapy to treat my cancer, would you get "paternalistic" on me and direct me to the care that your years of training and the scientific process has showed you to be the most effective or would you allow me to proceed down the road of these alternative approaches under the guise of being "open-minded"? I anticipate a response like,"I would encourage you to use 'allopathic' medicine while exploring these alternative therapies". I am however wondring if there is a point, say if I indicated that I was ONLY interested in homeopathy and reike therapy, at which you would feel a duty to step up and clearly put yourself in one camp or the other.

  4. Another whiney one...

  5. Speaking of being paternalistic, I am just wondering if you still think if I only need to talk to my daughter about sex instead of getting her the HPV vaccine? Because you still haven't told me how I am supposed to find her future husband to have that discussion you seemed to think was a good substitute for the vaccine in the discussion linked in my name.

    (And in the earlier post, I cannot imagine why anyone would want their children to get chicken pox! All three of my children got it the year before the vaccine came out, and it was a month of misery... two weeks of that was dealing with a six-month old who could not sleep. Since there is a Ronald McDonald house in this part of the city, there were at least four schools who asked children who were sick to stay home because the immune compromised patients and their siblings were attending those schools.)

  6. Dr. Zilberberg, on reading Dr. Novella's response, I find that he has criticised your position on equipoise. If you would remember, I made a similar observation about your argument on equipoise on doc2doc. I wait for your views regarding equipoise, meanwhile, I sincerely think that the pre-experimental probability of the plausibility of a new treatment modality should be taken into account while undertaking any study.

  7. When someone is making incorrect statements about reality, and someone points out the problems in these arguments, it can seem "paternalistic" to the person who is making such statements.

  8. I'm afraid I must agree with the first poster, Dr. Zilberburg. You have acknowledged the existence of Dr. Novella's retort but you have not really addressed it's content.

    To continue the discussion we need some meat on the plate, I think.


  9. Dr. Zilberberg, you write that Dr. Novella cherry picked your arguments. The examples he cites seem to me to be representative of your argument. Would you please explain how they are not?

  10. Thanks to everyone for their comments. I apologize that I have not been able to post any cogent responses that will advance the discussion yet. PLease, bear with me, as I am in a couple of all-day meetings, and will try to get to respond to all of the comments shortly.

    Over the next few days I will also try to respond to Dr. Novella's criticisms. This will probably be done in a series of posts, as there is a lot to digest in his remarks. I do want to address him with equanimity and this requires that I think about what he is saying, rather than knee-jerking into a response. I do apologize if my post above was slightly glib, but it will be followed up in the very near future.

    Again, thanks to everyone. It is through these disagreements that we arrive at better ways of understanding.

  11. In regard to the statement made by "moderation"

    "I am however wondring if there is a point, say if I indicated that I was ONLY interested in homeopathy and reike therapy, at which you would feel a duty to step up and clearly put yourself in one camp or the other."

    Of course there is a point where any clinician is duty bound to "clearly put yourself in one camp or the other"

    The fact is, however, that a skilled clinician knows how to avoid such a crisis in counseling from occurring in the first place. Sure; if a patient spurns my suggestions and prefers to proceed with an allopathic, non-proven course of action there may come a time where I say "it's my way or the highway, pal..."

    The challenge is to preemptively NOT get to that point. It's important to remember that any patient has the autonomy-driven right to handle their care in any way that they wish. This includes proceeding with allopathic care or seeking a second opinion.

    Indeed, I have been on the receiving end of patient's who "disagreed" with their physicians and sought to have another physician give the stamp of approval to their allopathic plans.

    In the vast majority of cases - such patients under the care of a second or third opinion end up proceeding with standard care (or at least a hybrid approach which includes standard care).

    It is rare for a patient to reject all medical evidence; and it is the role of a caring clinician to avoid letting a difference in perspective become an insurmountable obstacle to collaborative care.

  12. Hear hear onyeije!