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Faulty Sayings

2013 August 25
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Posted by Skeplanker

It is always fun to dissect news reports and play the game of “name that logical fallacy”. In fact, it’s the only way to feel less depressed about the quality of news nowadays.

Recently I heard someone on the news saying “if this can happen, anything can happen”, which is of course a common saying and often repeated without thought. Really? Does the occurrence of an unlikely event increase the likelihood that another unlikely event will occur? Seems to be a case of Reductio ad absurdum, which is also a Non-Sequitur.

A more accurate way of conveying the concept would be “this shows that unlikely events do in fact occur”.

Of course they occur. Otherwise it wouldn’t be news.

Hardest Logic Puzzle

2013 August 25
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Posted by Skeplanker

I have come across “the hardest logic puzzle” and been fascinated with it and its variants.

It stems from the classic Knights and Knaves puzzle.

There are two boxes to choose from, one of which you must open. One contains a treasure, and one contains a bomb which will lead to certain death. There are two people who both know the contents of the box, a Knight (who always tells the truth) and a Knave (who always lies). You do not know which is which. You can only ask one person one question, and must determine which box to open based on his answer.

The classic solution, is to point to the other guy and ask the question “would he say this box contains the treasure?” and open the other box if he says “yes”.

Using an embedded question, you can get a consistent and meaningful answer.

Let’s try a difficult version of the hardest logic puzzle.

There are three gods (A, B, C). One will always speak the truth (T), one will always lie (L), and one is completely random (R). Completely random does not mean that sometimes he answers truthfully and sometimes lies; it means the answer itself is random. They all understand English, however each god must reply in his own language, either “ja” or “da”, which means “yes” and “no”, in no particular order. The three gods each speak a different language, and unfortunately “ja” or “da” could mean “yes” or “no” differently in each language.

You may ask three yes/no questions to accurately determine the identities of each god. Each question must be placed to one god only at a time, and the same god may be asked multiple questions, consecutively or not, meaning that some god may not be asked any question at all. You may not ask questions that potentially cannot be answered (e.g., Truth would not be able to answer “would you say ‘ja’ if it means ‘no’ in your language?”)

The way the unanswerable question was phrased gives a hint to how the puzzle can be solved. For this very elegant solution, go to Wikipedia.

Thoughts on Scalia’s Rant on DOMA

2013 August 6
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Posted by Skeplanker

DOMA is defeated, and Justice Scalia is not happy about it.  It is splattered over the media (huffpo , politico, etc.) about how he is throwing a tantrum like a child.  I found it rather strange that a Supreme Court Justice, who should be arguably one of the best logical thinkers and one of the brightest minds, would be portrayed so negatively in public media, so I decided to look into it a bit more in depth.

I looked up the original source on the SCOTUS website and read his dissent, which turned out to be more nuanced than what the media
are reporting.

The first part about actual jurisdiction actually does make sense, and he seems to make a relatively convincing argument.  However, not being a lawyer, nor well versed in the nuances of domain of jurisdiction, I cannot judge the validity intelligently.

His portrayal about the majority demonizing the minority (…the majority has declared open season on any law that…can be characterized as mean-spirited……To question its high-handed invalidation of a presumptively valid statute is to act … with the purpose to “disparage,” ”injure,” “degrade,” ”demean,” and “humiliate” our fellow human beings, our fellow citizens, who are homo­sexual.  All that, simply for supporting an Act that did no more than codify an aspect of marriage that had been unquestioned in our society for most of its existence…) is worth looking at.  Scalia points out that the lawmakers did not necessarily act in malice by supporting DOMA.  It seems true based upon
the language of the majority decision, and I would speculate that the court majority came to that conclusion in hindsight.  After all, slavery, also sanctioned by the Bible, seemed like a good idea back in the days.  However, the reality is that this act was enacted in 1996, not 1896.  I believe that a lawmaker owes it to their constituents to think everything through and understand exactly what they are voting on, and what that legislation implies BEFORE they act.  Sadly, that is probably the last thing on their minds, with DOMA being one example but the PATRIOT act being a more egregious violation by far.  Outright malice?  Probably a stretch.  In my opinion, it is a lot more likely to be
the result of blind recklessness.  However this is simply an observation on the language of the judgment, and not an argument why DOMA should stand.  I agree with Scalia about the post-hoc reasoning and tribal-like false dichotomy; however it is off-topic.

His other rant about court sanctioned homosexual sodomy leading to a slippery slope (…when the Court declared a constitu­tional right to homosexual sodomy, we were assured that the case had nothing, nothing at all to do with “whether the government must give formal
recognition to any rela­tionship that homosexual persons seek to enter.”…), is what I have the biggest issue with.  This, I contend, is the main issue most conservatives find difficult to deal with.  The actual act of homosexual sex.  It disgusts or at least pretends to disgust them, and instead of risk exposing their bigotry and openly condemning the people that practice consensual homosexual acts, they employ different tactics such as deferring to a deity of choice or state legislation.

There are two main objections I have to this issue.  The first is that it is not the state’s business, or indeed anyone’s business aside from the participants, to be concerned with consensual sex, whether it is between members of the same sex or not.  A consensual act with no victim should not be a crime (and according to Lawrence vs. Texas, is not a crime).

The second objection I have is that this alleged disgust-turn-hatred obsession focuses on such a small part that it trivializes marriage to the physical contact of various body parts.  I would like to think that marriage is about commitment, partnership, companionship, intimacy, and above all, love.  Yes, physical sex is part of it, but I would argue that few get married with that as the primary motivation.  If the slippery slope argument is the best reasoning (non-technical argument) that can be put forward against gay marriage, then the strength of their argument is sad indeed, and Scalia should know that.

This is obviously a dividing issue that evokes strong emotional feelings.  A personal knee-jerk, visceral aversion towards a certain behavior (such as Pat Robertson’s here) should not be the basis for a law.  Rather, it is careful, solid reasoning that should prevail.  Paraphrasing Johnathan Haidt, pointing out reasoning flaws in a moral issue and expecting others to change their stance, is like wagging a dog’s tail with your hand and expecting it to feel genuinely happy.

What also bothers me is that Scalia, being a Supreme Court Justice, entrusted with immense power, can not only let emotion
contaminate his thinking, but also issue it as an official dissenting opinion.  Humans do not get it right all the time, and neither do groups of people like SCOTUS (case in point: Japanese internment during WWII).  However as a Supreme Court Justice, he owes it to the people to at least think clearly, carefully, and impartially on every issue that comes before him.  That is what the job entails.

I am also somewhat disappointed at the wording of the majority decision. It implies that participants in the legislation and enactment of DOMA acted in bad faith, with the express purposes of demeaning, discriminating, and influence on state legislation, largely ignoring the many legitimate federal issues DOMA addressed.  Although I am glad that DOMA is defeated, it does not quite leave a good taste.

Thoughts on Revenge

2013 April 19
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Posted by Skeplanker

 

Unlike reparation, most moral philosophers regard revenge as morally unacceptable, in the sense that harm is inflicted but achieves little to nothing for the revenging party, aside from satisfaction.  Revenge can be destabilizing because the harm inflicted is very often perceived by the receiving party as not proportional to the original encroachment, and can easily descend into a vicious circle such as a blood feud.

Our evolved, primitive sense of justice is the main driver for revenge, since it seems to be consistent across different cultures, and not limited to humans.  The primary motive for humans is to seek pleasure or satisfaction by inflicting harm to the perceived offending party, and perhaps as a secondary motive, to potentially deter future offenses.  Revenge is not necessarily justice, however that is not in the scope here.

What the revenging party gains is mainly emotional.  Namely, pleasure or satisfaction from knowing that the offending party has suffered as a result of his party’s action.

An operational definition of revenge according to Wikipedia is “a harmful action against a person or group in response to a real or perceived grievance”.  I think that this definition lacks some of the key psychological requirements central to revenge.

Let’s see what makes up revenge.  For simplicity, let’s call the party seeking revenge A, and the recipient party of the revenge B. 

First requirement, a perceived grievance against A, with B being the perceived offender.  Or is it?  Say B tortures a puppy unaffiliated to A, and A decided to whack B with a sledgehammer on behalf of the aforementioned puppy.  Is that considered revenge?  I would argue that it is, since A is taking pleasure in punishing B for actions that offended A, albeit  indirectly.  It would be considered as exacting revenge on a third party’s behalf.  Therefore, I would revise to be, “a direct or indirect harm or injustice perceived by A, with B being the perceived offender”.

Second requirement, intention of harm by A to B in direct response to said perceived offense.  If there is no intention, it cannot be considered revenge.  Say A accidentally runs over B with a truck unknowingly.  A can certainly take pleasure in this development, however it cannot be considered revenge, since there had not been an intention to do so FOR the original grievance.  At best it can be considered “karma”.  But not revenge.

Third requirement, formulation of a plan by A to inflict harm upon B.  Or is it?  Say B happened to walk under a piano and A saw the opportunity and decided to cut the rope holding the piano, flattening B in the process.  That would certainly be considered revenge.   There is no advance planning, only a snap decision in face of a fleeting opportunity.  So scratch that requirement.

New third requirement, actual infliction of harm upon B through conscious action or inaction by A.  Say B is drowning and A declines to act to save B.  That would certainly be considered revenge.  What about the conscious part?  Say B is drowning with 9 other people.  If A consciously decides to save others and not B, that is certainly revenge.  However if A simply clams up and does not save anyone, then it would be hard pressed to call it revenge.

Fourth requirement, derivation of satisfaction or pleasure for A from the infliction of harm to B.  Or is it?  Say B drowned as a result of A declining to act.  However after doing so,  A did not derive any pleasure, contrary to what he had thought he would.  Is that still considered revenge?  I believe most would say yes.  So what was wrong with the requirement?  I argue it is the anticipation of pleasure or satisfaction that is essential, and not the actual outcome.  Therefore, I would revise the requirement to be, “anticipation of satisfaction or pleasure for A from the infliction of harm to B”.  It is irrelevant whether said satisfaction is actually experienced or not.  So what, then, is the act of revenge without anticipation of pleasure?  I would call it a form of retribution.  It seems more like the governmental justice system, indifferent and detached.

Final requirement, B knowing or guessing to a reasonable certainty that said harm was inflicted by A, in response to a previous perceived grievance.  Or is it?  Does B have to know that the harm was inflicted by A for the revenge to be valid?  It would certainly be more satisfying to A knowing that not only had perceived justice been done but also that B was aware that it had been doled out by the wronged party.  Most would agree that this proposed requirement is not essential to revenge.  It would require significant mental discipline on A to resist the natural urge to gloat, and realize that there is no real upside to B knowing.  It is a comparatively rational form of revenge, and in my opinion the only type that ends the vicious circle.  So let’s scrap the final requirement.

Revenge is therefore better defined as: “Inflicted harm through conscious action or inaction in direct response to perceived direct or indirect grievance, with anticipation of satisfaction or pleasure from the infliction of said harm”.  I am probably committing great offenses to the English language here but hey, this is my blog.

Take the recent bombing at the Boston Marathon as an example.  Currently the perpetrator is unknown, and no party has claimed responsibility yet.  It is probably reasonable to speculate that it is likely to be an act of revenge, rather than a ill conceived test or stupidity gone awry.  Should the responsible party not come forward at all, I would argue that is a more effective modality of revenge.  Not that I condone the bombing in any way; this is simply my opinion on the nuances of revenge execution.

Professor and the Student

2013 March 22
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Posted by Skeplanker

I’m sure many have seen the following article posted and reposted.

————————–

Professor : You are a Christian, aren’t you, son ?
Student : Yes, sir.
Professor: So, you believe in GOD ?

Student : Absolutely, sir.
Professor : Is GOD good ?
Student : Sure.
Professor: Is GOD all powerful ?
Student : Yes.
Professor: My brother died of cancer even though he prayed to GOD to heal him. Most of us would attempt to help others who are ill. But GOD didn’t. How is this GOD good then? Hmm?
(Student was silent.)
Professor: You can’t answer, can you ? Let’s start again, young fella. Is GOD good?
Student : Yes.
Professor: Is satan good ?
Student : No.
Professor: Where does satan come from ?
Student : From … GOD …
Professor: That’s right. Tell me son, is there evil in this world?
Student : Yes.
Professor: Evil is everywhere, isn’t it ? And GOD did make everything. Correct?
Student : Yes.
Professor: So who created evil ?
(Student did not answer.)
Professor: Is there sickness? Immorality? Hatred? Ugliness? All these terrible things exist in the world, don’t they?
Student : Yes, sir.
Professor: So, who created them ?
(Student had no answer.)
Professor: Science says you have 5 Senses you use to identify and observe the world around you. Tell me, son, have you ever seen GOD?
Student : No, sir.
Professor: Tell us if you have ever heard your GOD?
Student : No , sir.
Professor: Have you ever felt your GOD, tasted your GOD, smelt your GOD? Have you ever had any sensory perception of GOD for that matter?
Student : No, sir. I’m afraid I haven’t.
Professor: Yet you still believe in Him?
Student : Yes.
Professor : According to Empirical, Testable, Demonstrable Protocol, Science says your GOD doesn’t exist. What do you say to that, son?
Student : Nothing. I only have my faith.
Professor: Yes, faith. And that is the problem Science has.
Student : Professor, is there such a thing as heat?
Professor: Yes.
Student : And is there such a thing as cold?
Professor: Yes.
Student : No, sir. There isn’t.
(The lecture theater became very quiet with this turn of events.)
Student : Sir, you can have lots of heat, even more heat, superheat, mega heat, white heat, a little heat or no heat. But we don’t have anything called cold. We can hit 458 degrees below zero which is no heat, but we can’t go any further after that. There is no such thing as cold. Cold is only a word we use to describe the absence of heat. We cannot measure cold. Heat is energy. Cold is not the opposite of heat, sir, just the absence of it.
(There was pin-drop silence in the lecture theater.)
Student : What about darkness, Professor? Is there such a thing as darkness?
Professor: Yes. What is night if there isn’t darkness?
Student : You’re wrong again, sir. Darkness is the absence of something. You can have low light, normal light, bright light, flashing light. But if you have no light constantly, you have nothing and its called darkness, isn’t it? In reality, darkness isn’t. If it is, well you would be able to make darkness darker, wouldn’t you?
Professor: So what is the point you are making, young man ?
Student : Sir, my point is your philosophical premise is flawed.
Professor: Flawed ? Can you explain how?
Student : Sir, you are working on the premise of duality. You argue there is life and then there is death, a good GOD and a bad GOD. You are viewing the concept of GOD as something finite, something we can measure. Sir, Science can’t even explain a thought. It uses electricity and magnetism, but has never seen, much less fully understood either one. To view death as the opposite of life is to be ignorant of the fact that death cannot exist as a substantive thing.
Death is not the opposite of life: just the absence of it. Now tell me, Professor, do you teach your students that they evolved from a monkey?
Professor: If you are referring to the natural evolutionary process, yes, of course, I do.
Student : Have you ever observed evolution with your own eyes, sir?
(The Professor shook his head with a smile, beginning to realize where the argument was going.)
Student : Since no one has ever observed the process of evolution at work and cannot even prove that this process is an on-going endeavor. Are you not teaching your opinion, sir? Are you not a scientist but a preacher?
(The class was in uproar.)
Student : Is there anyone in the class who has ever seen the Professor’s brain?
(The class broke out into laughter. )
Student : Is there anyone here who has ever heard the Professor’s brain, felt it, touched or smelt it? No one appears to have done so. So, according to the established Rules of Empirical, Stable, Demonstrable Protocol, Science says that you have no brain, sir. With all due respect, sir, how do we then trust your lectures, sir?
(The room was silent. The Professor stared at the student, his face unfathomable.)
Professor: I guess you’ll have to take them on faith, son.
Student : That is it sir … Exactly ! The link between man & GOD is FAITH. That is all that keeps things alive and moving.
P.S.
I believe you have enjoyed the conversation. And if so, you’ll probably want your friends / colleagues to enjoy the same, won’t you?
Forward this to increase their knowledge … or FAITH.
By the way, that student was EINSTEIN.
I hope you LEARN get additional KNOWLEDGE upon reading this STORY.
THANK YOU
LIKE & SHARE
REPOSTED by:
Creator: Prince Akhiro Sangukho

—————–

First of all, this article is using a psychological trick called the framing effect.  The accompanying picture shows a roomful of young students with one raising his hand, against a background of a huge blackboard full of information, with a man standing in front of it, supposedly the teacher or professor.  The reader is primed to see the professor as an authoritative and presumably intellectually superior figure, with the student being the underdog.  The two sides are already on an unequal footing, which makes for a good story (David vs. Goliath) but is intellectually dishonest and misleading.  Ideas should stand and fall on their own merit – who or how it is delivered should not make a difference.

Specifically:

Professor: Science says you have 5 Senses you use to identify and observe the world around you.

The truth is that our senses only give us an approximation of reality, and is biased to what has evolutionarily been relevant to us.  Our brain constructs a scenario based upon biased input from the senses, often ignoring conflicting or dissonant information.  Relevant examples include optical illusions, inattentional blindness, etc.  Science actually tells us that our senses are fallible and unreliable, and the scientific method can minimize or eliminate observer’s bias.  The implication of the author is that science relies solely only on the 5 senses (untrue).  So, the statement implies that religion does not rely on the 5 senses.  And what would religion rely upon?  Superstition?  Telepathy?  Magic?  Literature from the Bronze Age?

Professor : According to Empirical, Testable, Demonstrable Protocol, Science says your GOD doesn’t exist. What do you say to that, son?

Science does not say that something does not exist simply because it is not empirical, testable, or demonstrable.  For example, as of today, we do not know that there is life outside of earth.  No evidence has emerged so far.  Yet no self respecting scientist will say that life outside of earth does not exist.  The default position of science is “we don’t know”.  To say that life exists outside of earth simply because there is no disproving evidence, is violating the null hypothesis, and a clear logical fallacy (ad ignorantiam).  Extraordinary claims require extraordinary proof.  Absence of proof is not proof of absence; and certainly much less proof of existence.

Student : Since no one has ever observed the process of evolution at work and cannot even prove that this process is an on-going endeavor. Are you not teaching your opinion, sir? Are you not a scientist but a preacher?


An opinion carries far less weight when it is not supported by evidence.  Evolution is not an personal opinion, but a well-formed and widely accepted theory, which in particular does not require immediate direct personal observation.  The usefulness of a scientific theory lies in its usefulness in not only explaining past occurrences, but more importantly, generating testable and falsifiable predictions.  If the prediction turns out to be false, then the theory must be revisited and possibly rejected.  There is ample evidence of evolution from fossil records and DNA analysis, and the theory generates predictions such as the existence of intermediate fossils that can and have been found.  Intelligent Design is, to the extent of my knowledge, not falsifiable, adds no knowledge or understanding, produces no useful prediction, and thus does not qualify as a theory, much less a valid competing theory.

Contrary to what the story says, electricity and magnetism are well studied and understood.  But for a moment let’s suspend reality and say that scientists do not understand the ultimate nature of electricity or magnetism.  Through observation and experimentation, they still devise the laws and equations of the behavior, and formulate a theory and use this as the basis to make electrical circuits and motors successfully.  The theory still produces demonstrably useful results, as evidenced in the medium in which I am posting and you are reading.  A theory is useful because it explains how things work and predicts how things will work.  It is not necessary to know how an electron originated for the theory to be useful.  Not knowing the origin does not diminish its usefulness nor does it invalidate the theory, much less turn into an opinion that can be dismissed.  Not knowing everything is not the same as not knowing anything.  That is a false dichotomy.

Student : Is there anyone here who has ever heard the Professor’s brain, felt it, touched or smelt it? No one appears to have done so. So, according to the established Rules of Empirical, Stable, Demonstrable Protocol, Science says that you have no brain, sir. With all due respect, sir, how do we then trust your lectures, sir?


The premise is that something has to be tangible to the senses to exist.  It is true that it is possible that by some freak of nature that the professor has no brain.  However any sensible person would consider that as highly unlikely, since so far every professor that has existed has been shown to have a brain, post mortem or otherwise.  Additional evidence can be obtained from X-rays, CAT scans, or a variety of other methods.  Absence of immediate, tangible evidence is not proof of absolute absence of evidence.  For example, not having $10,000 in my pocket right now could be because that I do not have that much money, or that I have it but simply not in immediate possession.  It proves neither scenario.

The point about not trusting the lectures is spot on, but for the wrong reasons.  It is always healthy to question authority, be it a professor or other authority figure.  An argument should always stand on its own, not because someone simply says so, it is popular, or because it is “ancient wisdom” (argument from authority/ad populum/antiquity).

Professor: I guess you’ll have to take them on faith, son.
This sounds more like something said by a pastor, not a person of science.  It is rather unusual for a professor to call out a student for his religious beliefs, and even more unusual that he would address the student as “son”.

By the way, that student was EINSTEIN.

This has been shown to be false (see link).  First of all, Einstein, being Jewish, was not a Christian.  Secondly, this line of thinking is not consistent with Spinozism, the philosophy Einstein seemingly favors in his writings.

“Never let facts get in the way of a good story”.  If only it were a good story.

Health Freedom, continued

2012 November 22
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Posted by Skeplanker

This is the raw dialogue between myself and BillyJoe7 on Dr. Novella’s excellent Neurologica blog.  I thought it was worth posting because I would like to expand a bit on the thought process behind it.  I apologize for the horrible formatting (blame Mycrowsoft).  It starts out with Dr. Novella talking about the standard of medical care, and ends with me shamelessly hijacking the topic.

  1. # Steven Novellaon 24 Oct 2012 at 11:32 pm

    raylider – that’s why I added “because of the tremors.” They are not a good reason to evacuate. That would mean it’s reasonable to evacuate every city after every tremor (or at least ones in earthquake areas).

    If a patient asks me, “should I get an MRI scan,” and the official evidence-based recommendation is no, I tell them no, not “it’s up to you.” They may have a tumor – anyone might – and that absolutely opens me up to lawsuits. But I’m relatively safe if I am following the science and the standard of care.

  2. (deleted)
  3. # raylideron 25 Oct 2012 at 1:06 am

    Dr. Novella,

    Thanks for the reply, but I have a further inquiry regarding the ethics of the following:

    “If a patient asks me, “should I get an MRI scan,” and the official evidence-based recommendation is no, I tell them no, not “it’s up to you.” They may have a tumor – anyone might – and that absolutely opens me up to lawsuits. But I’m relatively safe if I am following the science and the standard of care.”

    — Shouldn’t it be up to the patient? Yeah, the headache is 99% likely to not be a tumor. But if your prescription is to always not get an MRI, you will have a 100% chance of being wrong at least in the instance of the 1% chance that it is the tumor. I would guess the reason that you don’t say “it’s up to you” is because it’s not the patient’s money/resources to be commanding because insurance/government are paying. Given that the patient comes in with cash and their own money, shouldn’t it be up to the patient to decide whether he wants to investigate unlikely scenarios? Is it likely that it’s a tumor? No, it’s highly unlikely. Do you know for sure: no. Caveat: there are instances where unwarranted diagnostic tests are harmful by increasing the likelihood of a false positive, as in the case of a low prevalence disease and a test that isn’t specific enough, but let’s assume that was not a factor for the purposes of this argument.

  4. # raylideron 25 Oct 2012 at 1:08 am

    P.S. Can you clarify what opens you up to lawsuits? Saying “no” or saying “it’s up to you”?

  5. (deleted)#

  6.  BillyJoe7on 25 Oct 2012 at 6:12 am

  7. Raylider,

  8. “Shouldn’t it be up to the patient?”

    No, it should not. Resources are limited. If everyone with a headache wanted, and got, an MRI, patients who have real indications for an MRI will be pushed to the end of a very long queue. They are the ones who are more likely to have a brain tumour and they will have a delayed diagnosis.

    “Yeah, the headache is 99% likely to not be a tumor.”

    Try 99.999%

    “But if your prescription is to always not get an MRI, you will have a 100% chance of being wrong at least in the instance of the 1% chance that it is the tumor.”

    Clearly, Steven Novella is not going to miss 100% of brain tumours that cross his desk.
    Obviously, if the headaches are accompanied by other suggestive symptoms, or if there are abnormal neurological signs, that would probably constitute a science-based ndication to do an MRI.

    “Given that the patient comes in with cash and their own money, shouldn’t it be up to the patient to decide whether he wants to investigate unlikely scenarios?”

    They would still be using up scarce resources (manpower, MRI machines), and some poor individual is going to miss out on his science-based indications for the scan or have a delayed diagnosis. If you think that is ethical, you have a different ethical sense than most doctors (I hope).

    “there are instances where unwarranted diagnostic tests are harmful by increasing the likelihood of a false positive, as in the case of a low prevalence disease and a test that isn’t specific enough, but let’s assume that was not a factor for the purposes of this argument.”

    Done.

  9. (deleted)

  10. # skeplankeron 25 Oct 2012 at 10:26 am

    Raylider and BillyJoe,

    If public resources are to be spent on an unlikely tumor expedition against the current standard of care, then it is clearly unethical.

    However, if the patient is sufficiently informed of the risks and benefits, false positives and negatives, and is still willing to devote his resources to get the optional MRI, unless a public hospital will bump a patient in need for an optional scan, I see no ethical problem with this.

    For example, in many parts of Asia, private MRIs are quite affordable and not uncommon. It is often less than a co-pay in the US (USD$200-$400 all inclusive, http://www.cth.org.tw/02department/depa02_5center8.html). Disclaimer: just an example, I am not associated in any way with this organization.

    On a tangent, I believe that a greater ethical problem arises when the cost of health care is artificially inflated due to an inefficient insurance system, and rendered inaccessible to millions as a result. When a health care provider will gladly accept self-pay for 1/10 of the price they bill the insurance company, something is seriously wrong.

  11. # raylideron 25 Oct 2012 at 12:23 pm

    BillyJoe7,

    “They would still be using up scarce resources (manpower, MRI machines), and some poor individual is going to miss out on his science-based indications for the scan or have a delayed diagnosis. If you think that is ethical, you have a different ethical sense than most doctors (I hope).”

    MRI’s are scarce? Why are they scarce? I don’t think a person who brings their own money is using anyone’s resources other than his own. It’s not as though a unit of MRI disappears because he used it. The patient traded his money, which can then be used to create more MRIs. It’s not as though when you buy an iPhone, there are less iPhones to go around. No, Apple uses the money to make more iPhones that are cheaper and better. So I’m not sure why that doesn’t apply to MRIs.

    May be I’m focusing too much on the hypothetical here, since we have a government controlled healthcare system and few people actually pay for their services. But given the exception when it is the patient’s personal resources at stake, it is absolutely ethical for him to trade his resources for other’s products. No one else is anymore entitled to someone else’s property.

    I’d say it would be unethical for the doctor to be the one that decides how to ration resources and place prices on other people’s lives. Yeah that’s great that the chance is 99.999 in the patient’s favor, but tell that to the family of the patient who went home with a tumor. The fact of the matter is, when the patient presents, the probability of him having a tumor is actually either 0% or 100%. And the 99.999 is the epidemiological figure derived from past populations, it does not apply to the individual. Also, it may be that in the case of the headache, the likelihood of a tumor is low, but the general cut off for most can’t-miss-Dx’s is what? 98%? You’re at 98% confidence that the patient didn’t have an MI, or PE, or whatever else? So you’re going to miss 2% out of every hundred and send them home? This happens all the time. Now, in the current system there is no other way, but I don’t see a problem with a person deciding how to care for themselves and using their own resources.

  12. # raylideron 25 Oct 2012 at 12:31 pm

    In fact, as you say “if every patient came in and got an MRI.” How AWESOME would that be? You would have tons of patients, paying out of pocket for MRI scans. The industry would boom, and the economy of scale would reduce the prices of MRI’s for everyone, while increasing quality.

  13. (deleted)

  14. # BillyJoe7on 25 Oct 2012 at 4:48 pm

    Raylider & skeplanker,

    You are talking about a different category or resources than I am.
    I’m not talking about personal financial resources, I’m talking about the world’s resources in time, money, and manpower.

    Not everyone can become a radiographer or radiologist. Of those who can, not all would want to be one. So there’s a limit already. Also governments, quite rightly, regulate to some extent how many go into the various professions. And there are market forces, but they don’t work as you suggest. If there is a siphoning off of a large section of they population into the lucrative fields of radiography, radiology, and MRI machine manufacturing (because everyone with a headache wants an MRI), there will not be enough farmers to feed us, carpenters to build our houses, and teachers to teach us how to do all these things.

    So there’s no choice. Radiographers, radiologists, and MRI machines are going to be rationed, whether we like it or not. The question is how do we ration them. The obvious answer, at least for readers of this blog, is based in science, not personal financial resources. It is also the ethical solution.

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  16. # skeplankeron 25 Oct 2012 at 9:14 pm

    BillyJoe,

    We are talking about the same resource, specifically the alleged scarcity of MRIs and radiologists. From my previous post, “For example, in many parts of Asia, private MRIs are quite affordable and not uncommon.”, the market forces have already brought the pricing down to an affordable level in those regions, where there had been, but no longer is, a rush of capital flowing into MRI imaging equipment investment, specifically self-pay private comprehensive health check-up clinics in Asia. The cost of a self-pay comprehensive 2-day health check was cut more than half to a bit over 1k as the number of clinics flourished. The public health system and resources were not impacted significantly as the clinics are private, for-profit organizations or branches. THAT is how the market really works. There have been no reports of people on public health care systems being denied MRI scans because the hardware and personnel were snatched up by private clinics.

    “A siphoning off of a large section of the population” is a strawman argument. A large section of the population woud also love to be the CEO of Mycrowsoft and make obscene amount of money. I’m sure most of them didn’t become CEO so they could be farmers and feed everybody to avoid extinction of the human race.

  17. (deleted)
  18. # BillyJoe7on 26 Oct 2012 at 6:22 am

    skeplanker,

    ” The cost of a self-pay comprehensive 2-day health check was cut more than half to a bit over 1k as the number of clinics flourished. ”

    A useless health check is still a useless health check when it is half-priced.

    Medical practitioners should be deciding what investigations should be performed. If there are clear evidence-based indications to do an investigation, it should be done unless the patient refuses. If there are clearly no evidence-based indications to do an investigation, then it should not be done and the patient should have no say in the matter. In the grey area between these two clear cut cases, then and only then should the patient have an input to the decision to do the procedure.

  19. (deleted)

  20. # skeplankeron 26 Oct 2012 at 1:05 pm

    BillyJoe,

    “A useless health check is still a useless health check when it is half-priced.”

    Your assumption is that a comprehensive health check is useless. Assuming it is a long shot (which arguably it is not), as long as the patient is properly informed, sometimes a hunt down a rabbit hole yields a rabbit.

    For example, a lottery ticket is a tax on those unfamiliar with the concept of expected value, and is one of the worst government-sponsored investments one can make. However, one should be free to squander funds on lottery tickets, despite what the mathematician recommends. Informed or not, it is the concept of free will. And in my opinion, this is exactly how CAM thrives minus the payout.

    “In the grey area between these two clear cut cases, then and only then should the patient have an input to the decision to do the procedure”

    I disagree with this viewpoint. In an extreme case, if Bill Gates wanted to buy an MRI machine and do MRI’s on himself, his dog, and dead fish, for any reason (health investigation, reclaim the Ig Nobel prize, etc.), nobody should have a say in how he spends his money, since an MRI machine is a commodity and not in short supply.

    Another distasteful example: People are free to purchase as many wasteful SUVs as they wish, and drive around in circles just for fun, even though this arguably wastes a limited resource (oil) and affects other (emissions).

    Unless one’s decision is clearly and directly affecting other’s well-being by depriving limited resources (e.g., monopolizing a resource), in my opinion one should have full agency of his own body, including how to utilize his available resources, and how and when to end his own life. It’s called freedom, and last time I checked, it was in the Constitution of the United States.

  21. (deleted)
  22. # BillyJoe7on 26 Oct 2012 at 2:31 pm

    Skeplanker,

    It is not my assumption. Routine health checks are not evidence based activities. In fact, the evidence is that they are not beneficial and do not save lives. On the contrary, they tend to lead to further useless chases down rabbit holes. The fact that occasionally a treatable problem is picked up is not a justification for their use.

    I don’t buy lottery tickets for that very reason, but if you want to buy one on a whim, go right ahead. But please do not waste limited medical resources on a whim. Medicine is not a commodity to be bought and sold on a whim, it is a scientific activity. Or it should be. Or don’t you support the purpose of this blog which is to promote science-based medicine.

  23. (deleted)
  24. # skeplankeron 26 Oct 2012 at 8:25 pm

    BillyJoe,

    “Routine health checks are not evidence based activities. In fact, the evidence is that they are not beneficial and do not save lives.”

    I would be interested in seeing this evidence. The following is the opinion of the NIH:

    “Regular health exams and tests can help find problems before they start. They also can help find problems early, when your chances for treatment and cure are better.”

    “Medicine is not a commodity to be bought and sold on a whim”

    I should stop buying aspirin then. Medicine, medical equipment, and medical services are commodities. You can buy it with money, and not have to rely on an authority to determine what is best for you or what level of care you must receive.

    “Or don’t you support the purpose of this blog which is to promote science-based medicine”

    I support SBM fully. But above all I believe in freedom.

    I believe that better education in critical thinking to be the long-term solution, which I feel is better than the Darwin way.

    This discussion is WAY off topic and I apologize to Steve for that.

    BillyJoe, if you want to continue discussion about health freedom, I suggest we do it here: http://notsofoulmouthedrant.blog.com/2012/10/18/health-freedom/

  25. (deleted)

  26. # BillyJoe7on 27 Oct 2012 at 1:01 am

    Skeplanker,

    The opinion of the NIH is not evidence.
    I’m not going to provide you with the evidence but, if you want to find the evidence for yourself, I will give you this reference as a starter:
    http://www.sciencebasedmedicine.org/index.php/re-thinking-the-annual-physical/

    And how is buying aspirin a whim?
    There is science-based evidence of benefit. Unlike an MRI for a headache.

    But health freedom?
    This is for health fraudsters to rip off the public without government interference.
    At least I know where you are coming from now.

  27. (deleted)
  28. # skeplankeron 27 Oct 2012 at 12:02 pm
  29. BillyJoe,

    From the first line of the link you posted:

    “Please note: the following refers to routine physicals and screening tests in healthy, asymptomatic adults. It does not apply to people who have been diagnosed with diseases, who have any kind of symptoms or signs, or who are at particularly high risk of certain specific diseases.”

    I agree with that disclaimer. However a blanket statement saying a health check is useless, or that further investigation of a symptom is useless, I cannot agree with. An MRI for a headache, depending on the nature of the headache, in my view can be possibly construed as “further investigation”. I reviewed Steve’s original post and it actually did not mention headaches specifically, so it was presumptuous of us I guess.

    I mentioned aspirin as an example to illustrate the fact that medicine is in fact a commodity, and in most cases if one chooses to procure more than is reasonably recommended, it can be wasteful but does not materially affect others, and one should be free to do so, however ill-advised.

    And the last point on fraudsters ripping off the public under the guise of health freedom, I would completely agree with that. My position is that even though I do not like, much less advocate, people being ripped off, people should have the choice to *voluntarily* be ripped off with informed consent. There is a subtle difference.

  30. (deleted)

  31. # BillyJoe7on 27 Oct 2012 at 3:56 pm

    Skeplanker,

    It seems your area merely confused by the terminology.
    A “health check” in medical parlance is a “routine physical”, and any test done as part of a “health check” is a “routine test”. Doing an MRI for a headache falls into that category. There must be additional symptoms or signs that lead to an evidence based decision to do an MRI.

    “people should have the choice to *voluntarily* be ripped off with informed consent. There is a subtle difference.”

    I think you’re confusing subtlety with confusion. (;
    I must remember that sentence:
    people should have the choice to voluntarily be ripped off with informed consent.

  32. (deleted).

  33. # skeplankeron 29 Oct 2012 at 1:24 am

    BillyJoe,

    I agree that there was imprecision when I used the term “health checkup”. It is not a “routine physical” but a “comprehensive screening test”, as “routine physicals” do not generally include the advanced screenng tests performed. I originally brought up the cost of this optional screening package to point out the fact that MRIs are neither scarce nor uncommon, and without explicitly saying so, implying that one could get an MRI scan even if insurance did not cover the expense. I argue that all this is irrelevant for the key issue that we differ on, which is whether a patient has the right to spend his own money on a medical procedure (specifically, an MRI test). You state:

    “If there are clearly no evidence-based indications to do an investigation, then it should not be done and the patient should have no say in the matter”

    My stance is that a patient should be free to do whatever he wants to himself, subject to limitations stated previously. In other words, if it on his own dollar, the patient should absolutely have a say in what treatments he gets or refuses, whether it is SBM or quackery.

    If a company is subsidizing the gasoline in an employee’s personal vehicle, which is recommended to run on regular, it would be unreasonable to ask the company to pay for premium. However the employee is free to believe in whatever woo he wants and fill up on premium, add in octane boosters, miracle fuel pills, and whatever useless additives money can buy, possibly causing damage to his own car, if it is on his own dollar. The same concept applies.

    That is “the right to be ripped off”. The difference is although neither of us think people should be ripped off, you think that people do not have the right to be ripped off, and I do. That is the subtle difference I am talking about, which hopefully is less confusing.

  34. (deleted)

  35. # BillyJoe7on 29 Oct 2012 at 6:46 am

    skeplander,

    If you support the science-based medicine promoted by this blog, then “health freedom” is out the window. Only medical experts can decide what is science-based medicine because only medical experts have the background knowledge, and the specific knowledge, and the working knowledge to make those decisions. To go with the decisions of non experts like patients against the advice of medical experts means giving up on science-based medicine.

    An additional reason why patients should not be allowed to use limited resources against science-based medical advice just because they can afford to do so, is because others with well-defined indications for testing for diseases that can be cured if diagnosed early, will end up with delayed diagnoses and worse prognoses.

    ” you think that people do not have the right to be ripped off, and I do”

    Yes, I’m no libertarian. People should be protected against fraudsters. Everyone, you and me included, is or has been at some stage of their life, vulnerable to being defrauded. I see no logic in assisting fraudsters by refusing to protect their potential victims.

  36. # skeplankeron 29 Oct 2012 at 8:42 am

    BillyJoe,

    I understand your viewpoint and although I respectfully disagree, I rest my case.

  37. (deleted)

  38. # BillyJoe7on 29 Oct 2012 at 2:02 pm

    skeplander,

    I think I understand your viewpoint as well, but I find it hard to respect it.

    Everyone for themselves is not even the law of the jungle.
    The law of the jungle includes reciprocal altruism and kin selection.
    I think we can do better than that.

I got too busy to continue on with the dialogue and I ended it.  However I do have some time now and will expand on it a bit here:

BillyJoe7:  “If you support the science-based medicine promoted by this blog, then “health freedom” is out the window. Only medical experts can decide what is science-based medicine because only medical experts have the background knowledge, and the specific knowledge, and the working knowledge to make those decisions. ”

SBM and health freedom are not mutually exclusive; that is a false dichotomy.  In a perfect world, medical practitioners are able to provide the best advice.  In the real world, medical practitioners are human, and can be spectacularly bad at assessment

BillyJoe7: “To go with the decisions of non experts like patients against the advice of medical experts means giving up on science-based medicine.”

First there is the faulty implied premise that getting an MRI scan (which is exploratory in nature) when evidence does not warrant it, is a decision that is *mutually exclusive* with SBM.  If it does not alter the course of treatment, it is simply wasteful and not mutually exclusive.  The conclusion does not follow in the MRI situation.  If a patient were to decide against taking life-saving drugs and favors prayer or magic, that is altering the course of treatment, and I concur that is giving up on SBM.

BillyJoe7: “Everyone, you and me included, is or has been at some stage of their life, vulnerable to being defrauded. I see no logic in assisting fraudsters by refusing to protect their potential victims.”

From a purely moral standpoint I agree with this statement.  I would also like to note that protecting people from their own stupidity is a noble gesture that is seldom well-received.  However, I am not against all forms of protection against fraudsters.  I am against an “absolute” protection in the form of an authoritative mandate, science-based or not.  In relevant terms per discussion above:

BillyJoe7 thinks that the patient does not have the choice to get an MRI, self pay or not, if the current guideline says it is unnecessary.

I think that once properly informed of the risks and benefits, the patient should be able to choose to undergo an MRI, if is willing to use his own resources and not materially affect others by doing so. 

The right to get an MRI should not be confused with the need to get an MRI.  For example, one should be able to get an MRI scan out of simple intellectual curiosity.  To mandate that one *must not* get one unless medically necessary even if using private resources, is not compatible with reality nor is it conducive to intellectual freedom.

Disclaimer: the context is different in that BillyJoe7 likely referred to the MRI for a headache, which is for diagnosis purposes.  My main point is that it should not be an authoritative mandate, for reasons beyond medical necessity.

BillyJoe7: “An additional reason why patients should not be allowed to use limited resources against science-based medical advice just because they can afford to do so, is because others with well-defined indications for testing for diseases that can be cured if diagnosed early, will end up with delayed diagnoses and worse prognoses.”

I agree if the premise of MRI resources were limited to the point where by getting an unnecessary MRI would deny someone in the immediate population that truly needed one.  That has been shown to be false.  People that would not be affected either way (remote villages) do not factor into the equation.

BillyJoe7: “I think I understand your viewpoint as well, but I find it hard to respect it. Everyone for themselves is not even the law of the jungle. The law of the jungle includes reciprocal altruism and kin selection. I think we can do better than that.”

Strawman argument.  I never advocated an “Everyone for Themselves” viewpoint.  I am not against some forms of regulation aimed at reducing quackery.  I am against absolute mandates that say “you must not do this because it is not compatible with our current understanding”.  I am ok with a regulation saying “this practice is not compatible with our current understanding, here are the risks of this unproven method, and if you choose to practice this on yourself, do it on your own dime”.

I fail to see the immediate relevance of “reciprocal altruism” and “kin selection” in this context.  In a Darwinian sense, those that choose to undergo ineffectual treatments will likely be not as successful in surviving and reproducing.  An authoritative ban may be a well-intentioned altruistic measure, but there is little reciprocation, and the social cost is difficult to measure.

I have two more analogies (I like analogies).

Tobacco, drugs, and alcohol.  Smoking is known to be hazardous, drugs have little social benefit, and excessive drinking is not conducive to well-being.  Banning tobacco and drugs, and banning binge drinking would be a science-based approach.  Yet that is not a socially acceptable option.  Most people would accept a warning label and education campaign.  Most would also accept regulation that limits its effects on others, such as second-hand smoke and public drunkenness, and driving under the influence.

Religion.   There is plenty of bigotry, intolerance, and hate in many of the prevalent monotheistic religions.  Yet it is stated in the Constitution of the United States, that people are free to worship any imaginary friend or friends of their choosing, as long as the practice is private and does not affect others.  Hence the separation of church and state, mosque and state, temple and state, FSM and state.

Freedom is not imposing one’s belief on others.  I stated “the right to be ripped off” just to make the point that I am willing to defend freedom, even if I do not agree with some of the consequences.

One thing I like about science blogs is that at least the conversations are more intelligent and the viewpoints more thought out.  Those who cannot formulate a coherent argument usually pick easier places to post their nonsense.

Any comments are welcome.

Health Freedom

2012 October 18
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Posted by Skeplanker

Freedom is a topic more complex than most realize; certainly more than I had realized.  In the sense of freedom of choice, more freedom does not necessarily mean one will be happier (see work by Barry Schwartz), nor does it mean that one will necessarily make the best decision (Bounded Rationality by Herbert Simon).  However that is the topic of another post.  Here I write my thoughts on the specific topic of health freedom.

On one extreme of health freedom is the days of the snake oil, where anything can be sold to anyone with any health claim, a full “buyer beware” system.  On the other extreme is an authoritative mandate that all must prescribe to an official course, scientific or otherwise, where one cannot decide on one’s own fate, even life or death.  Clearly neither are salient options.

In the US the situation is somewhere in between, with drugs and supplements regulated to a certain degree.  The National Center for Complementary and Alternative Medicine (NCCAM) is responsible for investigating complementary and alternative medicine scientifically, and this blog post shows how I feel about it.

Not too long ago, before widespread use of the internet, mainstream healthcare consisted of two words – “Doctor’s Orders”.  The MD was the expert, the professional, the authority.  Not many people were informed, and far fewer people misinformed.  A good old fashioned PDR was all that was needed.

The information revolution that came with the internet changed the entire landscape.  All of a sudden information is at your fingertips (whether one can properly make sense of it or not is a different story).  Unfortunately the driving force of the internet, the search engines, are designed such that search results are ranked based on popularity; accuracy plays no role in the ranking.  A vicious circle forms – medically accurate sites are unpopular because few understand the language, and the interfaces apparently have been designed by sadistic dysfunctional underpaid trolls on drugs, while quackery sites rise quickly by virtue of being written in plain English, sleek, well-designed, and have no shortage of salient material including false promises, unsupported claims, logical fallacies, plenty of anecdotes and “user testimonials”.

Suddenly to the physician, faced with a barrage of semi-informed inquiries, dubious questions, and the occasional legitimate inquiry of the latest e-pub clinical study that he didn’t even know about, that PDR seems about as useful as an outdated Yellow Pages, and the CME seems woefully inadequate.

Nowadays it is far more common for the physician to present options for treatment and defer the actual decision to the patient.  When done properly this is a reasonable approach, however it is time consuming and often impractical.  More often than not it is a way to shift the responsibility and provide an easy out for the physician.  Options are not equally valid simply because they are presented side-by-side, and although the physician is professionally obligated and morally bound to present the best objective expert opinion, sometimes it is not practical to present the options adequately for the often under-educated consumer to make an informed choice.

The bottom line is, although truly horrible decisions can be made with real harm and danger, I feel that a mentally competent adult should be able to make any choice regarding his/her own health, regardless of intent, up to extreme decisions such as suicide.  What I also feel is that one should NOT be free to impose his/her choice upon another person, regardless of intent, through action or inaction.

For example, one should be free to choose if, when, and how to die, be able to refuse treatment of any kind, and pursue whatever medical experiments on himself.  However one should not be free to impose this on anyone else, for example, people under his care, children, elderly, etc.  Parents should not be given free rein to decide whether their kid should get a qi manipulation instead of emergency surgery, or to replace life-saving medication with homeopathic concoctions; that is what I consider child endangerment.  It should be considered reckless endangerment when people with HIV knowingly have unprotected sex (inaction), even if one believes that he is cured of it through whatever modality.  Unless a subsequent test shows that one is HIV negative and no longer a risk.

This is my stance on health care, on religion, and on life.  One should be free to choose to believe in whatever they wish, be it scientific methodology, religion, magic, conspiracy, fairy tales, ideology, whatever.  One should be free to act upon those beliefs, as long as the effect is confined to himself or to willing and informed participants.  One should be able to believe in any monotheistic or polytheistic god,  but should not be able to blow up those who do not subscribe to the same view.

It would be easy to make a straw man argument that I should, by extension, oppose all regulation and advocate an anything-goes, buyer-beware snake oil system, which is not the case.  I am simply stating that people should be free to do whatever they wish when it comes to their own body, informed or not.

An informed decision is only as good as the information it is based on, and the process to come to that decision.  The information is only as good as the trustworthiness of its source, since few of us are directly involved in raw data.  The human mind has evolved not to think scientifically, and that is why opinions, reviews, and anecdotes influence our decision-making process more than it should.  Emotions aside, the reality is that it is difficult if not impossible to make an optimal decision on complex matters anyway, since we are limited by the information available, the cognitive limitations of our minds, and the amount of time to make a decision considering the cost of gathering and processing information.

I personally subscribe to the cautionary principle of “do no harm”, keeping in mind that inaction may be a better option than action considering the potential harm.  I consider evidence based on scientific merit only, and whenever possible I read and try to evaluate the methodology and quality of the underlying studies.  I try not to be influenced by anecdotes, testimonials, and personal biases, however that is self-delusional to a degree.  I will get a typhoid fever shot to protect myself if I know I will be served by Typhoid Mary, since it is quite clear to me that typhoid fever is caused by bacteria rather than “excessive heat/wind” or “imbalanced energy”.  To those that do not, hey, it’s a free country.  I promise not to judge, unless it presents a clear and present danger to others.

Drugs and Supplements

2012 October 17
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Posted by Skeplanker

Most countries have the equivalent of the FDA in the US, which regulates medicine and supplements to a certain degree. In 1994 the Dietary Supplement Health and Education Act(DSHEA) was passed, under which dietary supplements fall under. Of course having multiple industries and large amounts of money involved is not conducive to the best outcome for the consumer, but that is the reality. In colloquial and tribal terms, Big Pharma and Big Supplement got their territories carved out.

The main difference between drugs and supplements is that, for drugs, pharmaceutical companies are required to scientifically prove efficacy and safety, and claims can be made for the specific use approved. For supplements, unless it is a New Dietary Ingredient (NDI), manufacturers are practically free to do whatever they wish. Technically there are recent requirements to adhere to cGMP (2007, to ensure production quality), however in reality there is widespread non-compliance. It is up to the FDA to prove that a supplement is unsafe, and so far it has only done so on one occasion with ephedra, and nowadays does little more than posting warnings on its website and hoping people read them. Regardless of whom is to blame for the apparent lack of resources in the FDA, the fact remains that this part remains mostly unregulated.

One of the rationales behind supplements was that supplements were presumed to be safe because of long history of use. The huge cost of double blind, randomized controlled studies are prohibitively expensive and time consuming, and seemed like overkill for innocuous supplements. However, in reality, naturalistic fallacy aside, most supplements are far removed from their original states, with the active ingredient extracted and concentrated beyond what could have been reasonably consumed traditionally - much farther along the dose-response curve than its original form. In other words, an unregulated drug. There is no requirement for efficacy or safety studies. The reason you rarely if ever see a “Contraindications” section for supplements is not because it does not exist, but because it is not required and often unknown.

Of course, many of the supplements, especially traditionally known vitamins and minerals, have been well studied scientifically and the pharmacodynamic and pharmacokinetic properties are well known. Others have evidence ranging from peer-reviewed studies to fake anecdotes.  This graph beautifully shows some of the supplements, uses and current significant studies or lack thereof; the ranking is somewhat subjective but useful as reference.

My viewpoint is practical and some would say pessimistic or depressing.  I believe that regardless of multiple negative scientific findings, short of outlawing a product, actual behavior will not be significantly changed, due to confirmation bias, cognitive dissonance, distrust or just plain stubbornness.  It only takes one small scale, poor quality preliminary study with bad methodology, cherry picked data with dubious funding and strong researcher bias to be touted as the next miracle drug, I mean supplement.  The fact that journals rarely publish replication studies, especially when it contradicts prior claims, does not help instill trust either.  It is a sad but true reality.

Surprising Thoughts on NCCAM

2012 October 17
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Posted by Skeplanker

According to their website, the mission of the National Center for Complementary and Alternative Medicine (NCCAM) is to define, through rigorous scientific investigation, the usefulness and safety of complementary and alternative medicine interventions and their roles in improving health and health care.

In my view, NCCAM is more of a politically driven organization than a serious scientific establishment. The fact is that it has spent more than $1 billion on research with limited results, with positive results being from rather poor quality studies (size, blinding, methodology, etc.) and mostly on subjective reported results (pain).  The most celebrated recent headline grabbing meta-analysis on acupuncture (Vickers et al.) did conclude a very modest advantage on certain types of pain.  However from my understanding, the treatment efficacy when compared to placebo is only about 30-40% better than what you would get by randomly poking yourself with a needle or toothpick.  Honestly it is not what I would write home about but hey, everybody has different standards.

I surprise myself as I write the following, but this is how I currently feel:

Although it has been so far unproductive and arguably wasteful, contrary to what one might think, I actually have very little problem with the NCCAM’s existence, as long as it adheres to scientific methods. From a business point of view, this is simply a pet project, the cost of doing business. Their annual budget is less than $150 million, which is about what the US pays on interest alone on its national debt every 3 hours, in other words, petty cash. It is a relatively small price to pay to give a punching bag to a senator who has the view that “It is not necessary for the scientific community to understand the process before the American public can benefit from these therapies”. This statement makes the assumption that the therapy (bee pollen for allergy) is beneficial (not supported), is safe (not true, a 10 second search yielded this and this, ironically allergy-related), and needs no scientific evidence for the general public to use. Strangely enough, under DSHEA, bee pollen is a supplement and can already be used by the general public; you can take all you want, but simply cannot make claims that it can treat allergies. I find it sad and disturbing that someone with this thinking methodology is the chairman of the Senate Committee on Health, Education, Labor and Pensions.

Of course, there are moral implications. The layperson could take an investigation of a treatment (however implausible), hell, even the organization’s existence, and mistake it for an illusional, official endorsement. For example, if there were an official “National Center for Bigfoot Affairs” under the US Fish and Wildlife Service, it would not be unreasonable for the layperson to presume that Bigfoot existed.

I see it as part of the inefficiencies of the system.  For example, in a corporation, there are internal and external inefficiencies, key personnel get certain perks and privileges, pet projects, reciprocal back-scratching, you name it.  Yet often nothing is done about it, because the hidden cost of eliminating some of the inefficiencies far exceed the savings.  The savings realized by nickel and diming your employees to death are far exceeded by the price paid in lost productivity and loyalty.

Even though I have no problem with the NCCAM budget, it pales in comparison with the true cost, which is the enormous amount on money spent on CAM by the public under the misguided implicit endorsement of NCCAM.  I argue that the money would be spent anyway, with or without NCCAM.  I believe that most money spent on CAM is spent to feel good, to feel empowered, to feel that they are taking charge of their health, to feel liberated against Big Pharma, Big Government, Big Food, and Big Whatever.  The therapeutic value lies more in the patient/care provider interaction, a healthy dose of blissful ignorance, and reinforced by the act of spending itself (based on cognitive dissonance theory), rather than a measurable physiological effect.  Evidence-Based Medicine and Science-Based Medicine would likely disagree, but from a business, utilitarian, moral-free viewpoint, an immeasurable but nevertheless real benefit (unit of happiness, perception of pain relief) being traded for money voluntarily seems like a fair trade to me.

The real moral quandary is when people delay or forgo proven treatments due to their belief in CAM and cause real harm.  Too many of these happen unfortunately.  Although many can be considered Darwin Awards winners, many happen to babies, children, and those relying on help.  Those unable to care for themselves and most in need of help, through no fault of their own, are put in harm’s way by well-intentioned but ill-informed caregivers.  As tragic as the situation is, I callously argue that the existence, or lack thereof, of NCCAM would not likely significantly alter the situation.  The majority of decision-makers who chose the path to CAM-related serious harm and deaths likely possess a pathological mindset far too extreme to have their behavior influenced by the mere existence of a government organization.  A Taliban suicide bomber is unlikely to take off his bomb suit just because the Pakistani government opened up a National Center for Religious Tolerance.

In an ideal world, complementary and alternative medicine would be proven or rejected solely based on merit and high scientific standards.  In reality, CAM relies on a sympathetic governmental agency in which many would like to discount and discard the careful, rigorous examination process (not conducive to positive results) and treat opinions and anecdotes as data.  This is not an ideal world, and I settle for this.  I say let those that want to explore mysterious, unproven, implausible modalities do so.  If an effective therapy or modality emerges, great.  I await that day.

Analogies

2012 September 28
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Posted by Skeplanker

I love analogies, good and bad.  Used to illustrate a point or to ridicule, analogies are very powerful.

Without further ado, this is my bad analogy of the day:

“Unwillingness to change views in spite of evidence is like pressing on with Morgan Freeman’s funeral”