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”
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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
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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”
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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”
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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”
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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.
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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.
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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”.
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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.
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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.
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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.
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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/01QuackeryRelatedTopics/quackdef.html [reverified 12/2/2011]
Beauchamp, Tom L. and Childress, James F., Principles of Biomedical Ethics, 5th 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/s005200050175
Salow, Jeremy, “What is Skepticism: Evidence Based Critical Reasoning”, Philosophy, Suite 101,
http://jeremy-salow.suite101.com/what-is-skepticism-a95857 [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
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Kevin T. Keith
Non-Evidence-Based Medicine
Medical Ethics and Medical Quackery
Kevin T. Keith
ktkeith@ktkeith.com
www.ktkeith.com
www.sufficientscruples.com
@KTKeith
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Kevin T. Keith