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Robert Todd Carroll
If you suffered from chronic pain or hay fever from which you received no relief after many years and dollars spent on science-based treatments, wouldn't you become an advocate of chiropractic or homeopathy if you finally found relief after using one of these so-called alternative healing practices? Of course you would. You might even consider those of us who defend science-based medicine as idiots or charlatans who are either unwittingly deceived by the AMA or Big Pharma or consciously pulling a con on the general public. You might take offense at the suggestion that you've drawn a hasty conclusion in thinking that chiropractic or homeopathy is the real cause of your relief. You might say that if anyone needs to be reminded of the power of cognitive biases to deceive us into defending falsehoods, it is the scientists of the world, not you. You know you are right because you have the personal experience to prove it. No matter what all those randomized controlled trials (RCTs) show, you know firsthand what works and what doesn't.
Consider the following comments from someone I'll call Ricky:
My neck started hurting after a canoeing trip when I was 17 years old, then the pain crept down my arms and my hands became numb. I, of course, went to my doctor who sent me to a specialist who did many tests and then prescribed physical therapy, which did not help. The pain became so bad that I couldn't go to college, couldn't work very long, and was miserable all the time. After 4 years of many, many doctors, 2 surgeries, months of PT, OT, and "pain school" I finally went to a chiropractor. The pain level dropped immediately after an adjustment but then returned over a day or two, so I managed to get through college by going to a chiropractor every 2 days. Years passed this way. It sucked, but it was the best solution I could find and it was a hell of lot better than the alternative.
Then, one day a random person in a doctor's waiting room told me about a different type of chiropractic -- it was called Grostic back then, but NUCCA now. I found a chiropractor who practiced this technique and over a few months my neck/arm pain decreased significantly and for the first time in years I had actual time when I wasn't in pain. I was able to work full-time and actually have a life. And my trips to the chiropractor dwindled down to just once every month.
Do you have any idea what it's like to be in pain for years and then to have that pain stopped? It's an unforgettable experience. To attribute this to "regression" is laughable.
I did not seek chiropractic help for many years because I was a sensible, intelligent person. I had read articles about chiropractic quackery similar to yours and so I did not try this method. But, if I had been a little less skeptical, a little less smug about being so damned smart, I might have spared myself years of needless pain and suffering.
Maybe chiropractors don't know why their treatment works - it wouldn't be the first time that a pill or procedure worked without its practitioners understanding why.
From experience, I can tell you this; if you are in pain long enough you'll try anything that even has a shred of a chance at lessening that pain.
So, when I met a woman, a professor at a local university, who was in severe neck pain I was able to save her from years of suffering by telling her about my experience. She, like myself, was very resistant to chiropractic. So I told her this; "when you get tired of hurting here's the number of my chiropractor." A year later, I met her in my chiropractor's waiting room. She said she had been through all the medical procedures I had predicted they'd do to her and that none of it had worked. So one day she mustered her courage and dug out the card I gave her and set up an appointment. She'd been in treatment for 3 months when we met up again, and she said that her neck pain was nearly gone and that she'd been able to return to work.
Up until the day he retired, my chiropractor's office was filled with people like us whose lives had been all but thrown away by mainstream medicine -- and then redeemed by a chiropractic healer. I can't help but wonder how my life might have been if I'd met someone who could have directed me to a Grostic/NUCCA chiropractor when the pain first started. So many wasted years.
All I'm saying is that you might want to consider that there's a bigger set of possibilities on this one.
From what I can gather from this commentary, both women are still in pain but the pain is no longer debilitating to the point where they can't work or have a "normal" life. Both had surgery, physical therapy, and occupational therapy. It's not mentioned, but it seems likely both were prescribed some pain medication. In one case this went on for several years; in the other, it went on for a year. Both women then went to a NUCCA chiropractor and continue to do so, presumably because they are not free of pain. Thus, we can say that over a period of time their conditions improved and both credit the last intervention they sought as the sole cause of the improvement.
Is it possible that the science-based interventions did no good and the chiropractic alone has been effective? Sure. Is it likely? Not really. Given what we know about NUCCA, pain, and science-based medicine, the most probable explanation for the decrease of pain is either regression (though Ricky dismisses this suggestion outright) or the delayed effectiveness of the science-based interventions or a combination of the two. It is not unusual for a person to have surgery, physical therapy, or be prescribed drugs and not feel the benefits right away. For many people, chronic pain eventually reaches a peak and then subsides for no discernible reason.
Many people attribute relief from pain to their visit to the chiropractor because it was soon after that visit that they first experienced relief. That is one of the main reasons chiropractors are still in business despite the fact that there is overwhelming evidence that their craft is based on what has never been found ("subluxations") being relieved by the manipulation of something that's never been detected ("vital energy"). Post hoc reasoning is one of the most common cognitive biases and one of the more difficult to overcome because the personal experience of immediacy seems intuitively to justify the making of a causal connection. Contrary to what some people might think, making hasty conclusions about causal connections is not a sign of stupidity or idiocy. It is natural and the norm, which is why it is so difficult to overcome. If Ricky had argued that despite the fact that it was soon after she went to the chiropractor that she experienced significant pain relief, she would have been "abnormal" in the sense that her thinking would have been unnatural.
I should note that there are probably other factors besides the natural tendency to see causal connections based solely on sequence and temporal proximity that account for the popularity of so-called "alternative" practices. The attribution of causal effectiveness to the alternative treatment gives the patient hope and a sense of control over her condition. Even the fact that she is not cured but must continue treatments for years does not deter from the sense of empowerment that comes with the belief that one has finally found a "solution" to one's problem. The chiropractor might even suggest that without his wonderful, magical treatment, the pain will recur with a vengeance. Fear of the problem recurring provides a strong motivation to believe in the treatment.
It is also probable that some of the relief she is now feeling is attributable to the placebo effect. What is certain is that we can't know what would have happened to Ricky and the other lady had they not gone to the chiropractor. If only there were two Rickys, one of whom goes to the chiropractor while the other doesn't, then we could compare the two. If there were a significant difference in outcome, we'd have good reason to do further study to determine whether what we observed was a fluke or indicative of causal efficacy.
Fortunately, we do have many RCTs involving chiropractic and the evidence is overwhelming. We don't have to clone Ricky to know that chiropractic, including NUCCA, is, at best, placebo medicine. Even the claim that chiropractors are "back pain specialists" is a great exaggeration.
Before moving on to the next example of "experiencing is believing," I should note that there are thousands of Rickys out there who have had similar experiences with science-based medicine followed by magnetic therapy, reiki, acupuncture, faith healing, and dozens of other "alternative" treatments. These people are not idiots. They are "normal" folks reasoning in a quite natural way. That doesn't make them right, however.
another skeptic of science-based medicine
Consider the following comments from someone I'll call Abby:
Dear Mr. Carroll,
I am impressed with your work on ridding the world of superstitions. I am a journalist and I consider myself a skeptic. I am interested in questioning everything and finding the truth, however inconvenient and contrary to popular beliefs it may be. For this reason I left the Catholic Church twenty years ago and it is my ambition to apply reason in reporting and researching my subjects.
Six months ago I was intrigued by the debate surrounding homeopathy. I followed an online discussion between supporters and critics of this method and realized that since I have an array of chronic complaints that homeopathy supposedly can "cure" it will be easy enough for me to expose the fraud. To make the matter simple and diminish the possibility of placebo effect I did not consult a homeopath, just got some books and a collection of remedies from the local health store, spending around $300. That's what I was prepared to lose on quackery.
As a hay fever sufferer I first tested the allergy medicines. There were seven of them. The first one didn't show any effect. The second one brought almost instant relief. The rest were also ineffective. It was the end of May, plenty of pollen in the air, so I had ample opportunity to test the remedies again and again, and the results were the same - one remedy worked, the other ones didn't.
This baffled me, since apparently there is no chemical difference between these pills. I don't know if I should say any more, because I can see how by stating what I just stated I have become "the enemy" - victim of delusion and magical thinking. Especially since the next set of trials, on another one of my ailments, yielded even more spectacular effects.
Before considering Abby's more spectacular experiment, let me clarify a point. You do not become the enemy by being deluded and engaging in magical thinking. Magical thinking is the norm. As has been pointed out by many observers of human psychology, we are pattern-seeking animals. We are biologically driven to find patterns and this sometimes leads us to see patterns where there are none, to make causal connections where there are none. It is also natural and normal to be unimpressed by objective evidence that contradicts our understanding of personal experience. Being able to step back from our intuitive grasp of what's true and question what seems obviously the case based on our experience is very difficult and it does not come naturally to most people.
I bring this up because when I notified Abby that I planned to use her comments in this essay, she immediately wrote back (without having seen anything I'd written):
I am pleasantly surprised that my letter merited your attention and reply. I am, however, less than thrilled that you are planning to use it, if I understand you correctly, to argue that people who use alternative treatments are idiots who cannot identify cause and effect even with regards to the workings of their own bodies. This is a dehumanizing approach and I object to such use of the data I provided to you. You do not need my anecdotal evidence to prove or disprove or illustrate anything. I would rather you would comment on the number of double blind, placebo controlled trials of homeopathy that are available online.
I am surprised that a journalist would suggest that patients are the best judges of cause and effect with regard to their own bodies. We seek expert advice from medical professionals because we are not the best judges of such things. Even medical professionals, if they are wise, seek a second opinion of a self-diagnosis for a serious ailment. Many people diagnose themselves with all sorts of disorders that they probably do not have. Examples are endless, but currently there is a YouTube video making the rounds that is a poignant demonstration of the folly of the patient determining cause and effect with regard to her own body.
Desiree Jennings is a 28-year-old cheerleader who has become the poster child for the anti-vaccination movement based on her claim that a flu shot caused her dystonia. (I blogged about this case in a recent post involving "Jan," another adamant defender of falsehoods based on personal experience.) Jennings claims that she was healthy until about ten days after she received the seasonal flu vaccine last August. She then developed a severe respiratory illness that required hospitalization. Shortly after that she had difficulty speaking and walking, with involuntary muscle contractions and contortions. Her symptoms are relieved by walking backward or by running.
There is no known way that the flu (which is what probably hospitalized her) or a flu vaccine could cause dystonia and there is not a single case in the medical literature of such a thing ever happening. Still, there is always a first time, I suppose. But getting bogged down in that discussion is a red herring because it is very unlikely that Jennings suffers from dystonia. Several doctors, including neurologists, and the Dystonia Medical Research Foundation have viewed the video and believe that her symptoms are not consistent with dystonia ("or any organic movement disorder"*), but are consistent with a psychogenic disorder. The Dystonia Medical Research Foundation issued the following statement:
Because of the concern of individuals with dystonia as to whether or not to get a flu shot because of this reported case, we have sought the opinion of dystonia experts on this case. Based on the footage that has been shared with the public, it is their unanimous consensus that this case does not appear to be dystonia.*
Jennings is sure the flu shot caused her symptoms, but she is not the best authority on the subject of what caused her body to begin functioning in the weird and disabling way it now functions. The fact that she has found an expert to back up her belief and provide the cure should be carefully considered. The expert is Dr. Rashid A. Buttar who has declared that Jennings has been misdiagnosed and suffers from "Acute, Viral Post Immunization Encephalopathy and Mercury Toxicity with secondary respiratory and neurological deficits." Buttar has a history of defending falsehoods as an anti-vaccine crusader aligned with Jenny McCarthy and the others who blame mercury (or other "toxins") in vaccines for autism and a host of other ailments despite mountains of evidence that there is no such connection. Buttar, in short, is not the kind of dispassionate expert anyone should turn to in their time of need.
Anyway, I assured Abby that I did not plan "to argue that people who use alternative treatments are idiots who cannot identify cause and effect even with regards to the workings of their own bodies." She replied:
If you quote someone who says they were "cured" by [applied] kinesiology with the comment to the effect that there was no disease to begin with or it cleared "spontaneously" this is to me equivalent to calling that person mentally unfit to interpret their own experience.
The debate over alternative therapies is framed in such a way that sick people have to prove to the skeptics their common sense, while the skeptics sit in judgment as some new almighty god, above the human condition. This is very unhelpful.
I agree that it is unhelpful to judge others as if one were a god and others suffered from grievous mental defects. However, I do not consider offering an alternative explanation to someone who thinks he was cured of an allergy by applied kinesiology as in any way implying mental unfitness to interpret his own experience. What is unhelpful is to be so closed-minded as to not be willing to consider alternative explanations for one's experiences. The self is not an unbiased observer of one's experiences. Abby seems to be implicitly defending the notion that the self is the best and only qualified judge of experience. That notion has been shown to be wrong on so many levels that it seems pointless to discuss it further.
Obviously, nobody likes to be told they're wrong. Abby may think I am the one who is wrong. I would appreciate her correcting my errors, but I don't think people who use alternative treatments are necessarily idiots or mental incompetents. Not being able to identify cause and effect with regard to the workings of one's own body is the norm for humans and is not dehumanizing in any way. (As for the RCTs on homeopathy, I refer the reader to my exchange with a medical doctor who practices homeopathy. He chose what he considered to be the best RCT available in support of homeopathy and I evaluated it.) Anyway, here is Abby's story:
I am 45 and have never before experienced an ailment of any kind to completely go away in response to either conventional or alternative therapy (such as chiropractic or acupuncture), or even psychotherapy. Six months into the trial (not completed yet, I still have arthritis to deal with) I can no longer accept that homeopathy is a bogus medicine. I can also see why it is very difficult to prove its effectiveness in RCTs. My 7 year old daughter, who also has hay fever, did not respond to the remedy that worked for me, but responded to another which for me was ineffective.
My daughter and I have very different body types, metabolism, characters, etc. Therefore, it is easy for me to see how homeopathy doesn't stand a chance in RCTs on people sharing just one ailment. However, I believe if tested on people sharing a number of physical/psychological traits it will show its benefits well above the placebo effect.
I do not presume to convince you, since I know that solid facts in contact with a mind that is already made up become "anecdotal evidence." Still, I am thankful for the debate on homeopathy. Without it I would still be struggling with my chief medical problem, which had cost me over the past 10 years $8,000 dollars in hospital bills and various treatments, and had a debilitating effect on my work, relationships, and general quality of life.
I must have missed something. I was expecting the evidence that another trial on another ailment yielded more spectacular results than the hay fever trial, but all I see is a reference to arthritis as another of Abby's ailments that she "still has to deal with." Maybe she is referring to the fact that her daughter responded positively after taking a homeopathic remedy that evoked no response from her. Also, any science-based medical treatment must also be applied to people with different physiological and psychological profiles. Humans are too complex to assume that they are like cloned rats in a lab experiment. We're all familiar with the fact that some medications work better for us than others, and a medication that might be effective for you might cause me severe side-effects. That's the nature of the beast. Homeopathy need not be given a free pass on RCTs on the grounds that its medications are specific to each individual. In some sense, all medications are specific to the individual.
Anyway, homeopathic remedies have been tried on a number of people with similar physical and psychological traits unless by chance every homeopathic RCT involved people with radically different physical and psychological profiles. Anyway, Abby says that she did "a few minutes of research" and found a "number of double blind, placebo controlled trials of homeopathy that are available online." She wrote that she would rather have me comment on those RCTs than her anecdotal evidence. She would be right if my purpose were to demonstrate that homeopathy is bogus, i.e., just another form of placebo medicine. I've already done that in my homeopathy article. But the purpose of this essay is to demonstrate how normal, intelligent people are subject to cognitive biases that lead them to believe in the causal efficacy of alternative treatments despite the fact that there are mountains of evidence indicating that these treatments work by the placebo effect or are given credit for efficacy when credit is not due.
When one's experience clashes with overwhelming evidence, one can either dig in and look for confirmation of one's experience or one can re-evaluate one's interpretation of one's experience and look for alternative explanations in the form of cognitive biases that might be affecting one's objectivity. One does not become an idiot or a mental incompetent if one refuses to consider alternative explanations, but one does forfeit the right to consider oneself a critical thinker if one intentionally sets out to confirm one's biases. Not being a critical thinker does not make one mentally deficient, but it does increase one's chances of not only being wrong but of looking foolish in the effort to support one's error come hell or high water.
Abby refers to placebo medicine as "tricking...patients with sugar water instead of treating them." This is not accurate, however. My exchange with Jacob Mirman, M.D. and expert in homeopathy, should be sufficient to demonstrate that Dr. Mirman is not tricking anyone with sugar water. He is practicing what he sincerely believes is good, honest medicine. He is not a trickster, but is what author Jim Williams calls a "charlatan," an honest but misguided healer. Placebo medicine is a very complex affair, as is the whole business of teasing out the most efficacious therapy when one has undergone several kinds of treatments. The common response is to give credit to the last therapy used, but this disregards the delayed effects of earlier therapies as well as the fact that by the time one gets to the last of several therapies the ailment will have had plenty of time to resolve itself on its own.
I like Abby's experimental method, but at some point she will have to bring in others to the experiment or she runs the risk of completely deceiving herself. She needs two more experimenters to help her. The first takes her remedies and labels them with letters or numbers and records her labeling data. That experimenter then gives the remedies with their new labels to another experimenter (without revealing what is in each bottle) who gives the various remedies to mother and daughter when hay fever season is upon them, keeping a careful record of which remedy was given when and to whom. The patients determine which of the remedies is effective and which is not. After enough trials have been done (how many trials are needed is debatable), the first experimenter reveals which remedy was in which bottle. If the results match Abby's experience, we have good evidence that she was not deceiving herself and we move on to set up a large-scale study.
That is, we would set up a large-scale study if there had not already been many such studies that have come up blank and shown that homeopathy is at best a placebo therapy.
It's easy to understand why many people are advocates of so-called "alternative" therapies. They not only know they're right because of personal experience, but they can also point to scientific studies that support their position. They are not idiots or mentally defective simply because they are selective or mistaken in their interpretation of both their experience and the scientific studies. They do have what I call "belief armor" that makes them impenetrable to suggestions that there are alternative explanations that are better accounts of both their experience and the scientific studies they cite.
I do not presume to convince you, since I know that solid facts in contact with a mind that is already made up become "anecdotal evidence."
I don't know that solid facts become anecdotal evidence to a mind that is already made up, but I do know that when one feels personally attacked at the suggestion that there might be a better explanation for her experience, there is little hope that any arguments will penetrate her belief armor.
Critical thinking is not a natural act. We do not naturally seek out the nature of cognitive biases and how to avoid them. Critical thinking is made more difficult by the fact that there will always be others, some of them with fine-sounding letters after their names, who will confirm our interpretations of experience no matter what they might be. Communal reinforcement, joined with the natural tendencies to confirm our biases and see patterns where there are none, make causal errors an inevitable part of being human. It doesn't make us stupid or idiots, but it does make us prone to errors. We all fear uncertainty when it comes to our health and this fear can be easily exploited by others. Most of us don't realize how easy it is to find support for our beliefs from experts and scientists. It is not natural for most people to seek out all the evidence and interpret it fairly. Also, many people have idiosyncratic beliefs about health (e.g., if it's natural or organic, it must be healthy, but if it's synthetic or a pharmaceutical it must be unhealthy; or the world is toxic, so I must detoxify; or, the food we eat is inadequate, so I must take supplements). When you combine these factors with the human desire to be well, to be in control of our health, and to have hope that a problem is solved you have a recipe for creating impenetrable belief armor. We're all prone to magical thinking and to error. That doesn't make us idiots. It makes us human.
Critical Thinking by Robert T. Carroll
Teaching Critical Thinking by Robert T. Carroll
Clever fools: Why a high IQ doesn't mean you're smart There's a difference between being smart and being intelligent. That difference is the tendency to be curious and to think critically.
Last updated 21-Nov-2013