by R. Barker Bausell
Oxford University Press, 2007
Review by Kevin M. Purday on Sep 30th 2008
This is one of the most enjoyable books I have read in a long time! It is beautifully written, very humorous and yet very informative.
The author's intention is to inform his readers about the nature of science -- specifically how it works -- and to distinguish true science from the 'pseudo-science' that lies behind most Complementary and Alternative Medicine (CAM). The author is a research methodologist but he is usually content to tell people that he is a biostatistician as he thinks that the latter is less unwieldy than the former!
Rather than laboriously list all that the author does in this book, let me outline his position and then give you, kind reader, a feel for the delightful way in which he builds his argument.
The author is not only a biostatistician but he is also very much down that end of the spectrum which sees human beings as bio-mechanical organisms. This is not to criticize him but merely to make it clear where he is coming from. He sees illness as being caused by a bacterial or viral infection or some similar biological etiology. He sees medicine as the use of antibiotics to fight bacterial infection, the use of chemicals to destroy cancerous growths, etc. As he says at one point, effective drugs work whether the patient is conscious or unconscious. As a biostatistician, his task is to analyze, for example, drug trials to see whether a new discovery really does do what the manufacturer says it does by looking at the trials and applying very strict criteria. Those criteria would normally include using a fairly large number of participants, having a very small dropout rate, having an experimental group (who actually were receiving the new drug) and a placebo group (who were receiving what looked identical to the drug but actually was not) and a control group (who received no treatment at all or who were treated in a different way), employing a double-blinding technique i.e. neither the participants nor the clinicians running the trial knew which participants were in the experimental group and which were in the placebo group, eliminating other possibly pernicious variables, analyzing the results dispassionately and taking full account of nil results, using a demanding level of probability when saying whether the results could have been due to chance, etc.
The author is rightly scathing about much of what passes for scientific analysis in medical testing and particularly scathing about the lack of the above criteria when testing CAM products. He correctly points out that very few CAM experiments employ the strict safeguards mentioned above. In particular, he points out that CAM experiments normally result in a positive outcome because they do not usually have a placebo group (let alone a control group) and the positive result is actually the placebo effect kicking in. By this he means that CAM remedies do not act in the same way as biochemical remedies. The latter either effect a biochemical change in the patient's body or they do not. CAM remedies do not and should not claim to work in the same way. If they do claim to work in the same way (as, it could be argued, homeopathy claims) then they should be subjected to the same rigorous testing regime that biochemical medicines undergo. If they do not claim to work in the same way, then they fall into a different category and should be treated quite differently. A great number of CAM products and processes may well work but they operate psychosomatically through the placebo effect. For example, if the patient thinks that s/he is receiving some pain-reducing CAM treatment, this may well trigger the activation of the brain's opioid receptors and thus s/he may well report a decrease in pain. The important distinction is that biochemical treatments work (or do not work) directly on the organism while CAM treatments work (or do not work) by triggering psychosomatic changes in the patient.
The problem for this reviewer is that the author is firmly in the biochemical camp. There is nothing wrong with that but I do not think that I am alone in believing that the psychological aspect of being a human is essential -- it is not an optional extra. Therefore, although there is a place for the purely biochemical side of medicine (I for one would not like to live without the drugs that have made our lives so much more pleasant than was the case two hundred years ago), the psychological side of our existence must also be taken into account in many if not most areas of medical treatment. The crux of the problem is, I think, that people have to believe in CAM remedies if they are to have their psychosomatic effect. If we treat them in the same way as biochemical remedies and denigrate them as failing to live up to the standards required of their biochemical cousins, we run the risk of destroying their efficacy. There is a conundrum here: if CAM proponents claim that their treatments operate in the same way as biochemical treatments then biostatisticians are perfectly entitled to analyze the data with the same rigorous methods that they employ with biochemical drug trials. On the other hand, if CAM proponents were to claim that their treatments operated only via the placebo effect, then very few patients would feel the psychological benefit without which, for example, the opioid receptors would not be triggered. This reviewer does not know the way out of this conundrum but the issue needs to be raised.
This book, as was stated at the beginning, is beautifully written and humorously argued. The author has raised perfectly legitimate concerns and most of his criticisms are valid. CAM specialists need to read this book, digest the criticisms, and reflect on the medical and metaphysical issues that have arisen without feeling overly defensive. Both traditional Western (biochemical) medicine and CAM can in the long run only benefit from the arguments so clearly outlined in this book.
© 2008 Kevin M. Purday
Kevin M. Purday has just completed his fortieth year as a teacher and has recently returned to the U.K. after being principal of schools in the Middle East and Far East. His great interests are philosophy and psychology.