Paternalism of "science-based" medicine

This is a post I did originally for BMJ's doc2doc site. I am cross-posting it here for your convenience.

Lately I find myself getting more and more incensed with colleagues who seem to preach science-based medicine as the be-all and end-all in the truth about everything. I have blogged about this many times, and some of the references I make below are expanded upon in some of my recent posts. 

The argument goes like this: We who practice science-based medicine are the only ones that are correct in our approach because everything we do comes from a scientifically derived pool of evidence. Anything else is quackery, also referred to as "woo", which includes all modalities that do not fall in line with this EBM paradigm. They rail equally against healing crystal charlatanism, acupuncture, Reiki, and "anti-vaxers", lumping them all into the ignorant masses that dare go against what we "know" at their own and societal peril. They maintain that there is not room for anything in healthcare other than the "proven" scientific interventions.

So, if they advocate for science as the prevailing force in medicine, why should I, a firm believer in evidence as the backbone of healthcare, object? Well, here are some of my reasons, and let's see where you stand.

First of all, it is my belief that all interventions should be approached with equanimity, if not equipoise. Although I am quite dubious that either healing crystals or Reiki can produce actual results, I do not want to confuse the absence of any evidence to this effect with the evidence of absence of the effect. Although I am not that interested in allocating resources to studying these fields, it would be paternalistic of me to bar their further investigation. So the society can decide what it wants to do with them, and in the meantime every individual can make her/his own choice whether to spend their money on them. Interventions in the broad area of traditional Chinese medicine (TCM), including herbs and acupuncture, elicit less visceral aversion in me, and may be shown down the road to have desired health effects, though their study may not be amenable to our current methodologies. Again, at this time, if an individual wants to try them out, they should be keenly aware of how little we explicitly understand about them, including both their risks and potential benefits. 

The vaccine debate is yet another completely different issue altogether. In our privileged society the specter of infectious epidemics is for the most part but a distant memory, yet our concerns for the safety of our children combined with a rampant, albeit not altogether unjustified, distrust of the pharmaceutical industry and the government, have colluded to promote a biased yet durable suite of misinformation about the risk-benefit profile of vaccinations. Some of this prevailing sentiment may be because, in my opinion, we have focused on the wrong outcomes (e.g., the economics rather than morbidity associated with chicken pox), or that we have overstated what we really know and understand, at the risk of sounding too confident and therefore not trustworthy partners in this important area of public health. But these are just my own speculations. What is more important is what we do know about "science-based" medicine.

The uncomfortable truth about clinical science is that by its nature it is inexact. If it were precise, we would be able to describe it through simple mathematics without resorting to statistics, where the wild card is probability of an event. Relying on statistics is wise to understand what happens in large groups of subjects; it is altogether a mistake to take this information for God's own truth for any individual. As I have explained before, statistics are akin to that joke about assuming a spherical cow in order to help a farmer with his milk production quandary. The assumptions of normality, the dark art of log transformations, the cramming of a binary individual into a continuous distribution of population probabilities are all part and parcel of how we develop our understanding in the clinical sciences. No wonder when we bring this knowledge to the bedside a lot of the time it does not seem to apply to the specimen before us, and we are faced with having to use our judgment much more than the science-based medicine mavens are willing to admit. I often wonder how a 2-week prolongation in median survival in a cancer population, even if statistically distinguishable from the much-maligned placebo effect, is in practical terms all that useful. Yet these are effect sizes that we often see in science-based medicine.

My intent is not to belittle what clinical science has and continues to bring to the society. After all, thanks to it, we have a much better understanding of many illnesses now, and we can even take credit for effecting better outcomes for many a sick individual. At the same time we really need to sow humbleness in place of arrogance in all the places where the latter runs rampant. Philosophers of science have understood for decades that there really is no universal truth, and everything we think we know we understand through the prism of our collective human and individual experience. So, instead of wasting time on throwing boulders at our competition, why not take a closer look at the material that our house is made of. Dropping our inveterate paternalism in favor of being truthful about the degree of our uncertainty may make us look more human and fallible, yes. At the same time, it may show our patients and the public at large that we are on the same side. Though this is a risk, it is a necessary one to repair our rapidly crumbling therapeutic relationship. Admitting to not knowing is not only not a weakness, it is the only way to scientific progress.