Silence Dissent!

August 8th, 2008 by Ben Goldacre in alternative medicine, laws, stifling criticism | 19 Comments »

The CAM world meets a new all time low this week – even by their own standards – as the New Zealand Chiropractors Association threaten the New Zealand Medical Journal with legal action for criticising their ideas and practice.

Time and again we see alternative therapists using the law to silence dissent, and to prevent discussion of their theories and practice: in the UK recently we have seen such tactics from the Society of Homeopaths, herbal therapists and vitamin pill entrepreneurs (several recent examples coming shortly) to name just a few.

While chiropractors struggle to manifest to their customers an air of academic rigour, their actions in this letter demonstrate more than anything else how little they understand the simple day to day business of academic journals, journal clubs, work in progress seminars and indeed the entirety of medicine: we take the piss out of each others ideas. We criticise them. We tear them apart, mercilessly. When we criticise survival stats, or the interpretation and analysis of data, make no mistake: we are accusing each other of killing patients unnecessarily. This is the bread and butter of academia and medicine. Only very occasionally does anyone take personal offense.

This is a system that has grown up because when ideas are criticised, defended and discussed, they come out refined, and better. That the NZCA Inc should send legal threats to a medical journal tells you almost everything you need to know about the differences between alternative medicine and what everyone else is engaged in.

As the editor of the NZMJ says in his robust response: "let’s hear your evidence not your legal muscle."

When I speak, as well as the lovely ragers, I also meet a lot of very sensible alternative therapists who keep themselves firmly within ethical and stylistic boundaries. As I have said before, unlike the campaigners who write letters to the Times demanding that they are banned – call it the pragmatism of a man who has seen clinical practice a little more recently -  I am not entirely averse to a lot of these people plying their trade (and note please: I am disagreeing with Colquhoun and Ernst here, and they won’t hate me for it).

But the time has come for practitioners with any common sense to distance themselves rapidly from this kind of bullying behaviour, or watch their professions become a well-deserved mockery. Suing academic journals. FFS.


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19 Responses



  1. used to be jdc said,

    August 8, 2008 at 3:02 pm

    Good to see this being covered. Dr* T pointed out DC’s post on the Bad Science forum, but I hadn’t realised you’d posted on this until I saw the HolfordWatch piece on it.

  2. gadgeezer said,

    August 8, 2008 at 3:08 pm

    Can we say that this is declasse in the extreme and this letter will redound the reputation of the chiropractors while only emphasising the magisterial and measured response of Professor Frizelle?

  3. gimpyblog said,

    August 8, 2008 at 3:43 pm

    These are the tactics that the rich and powerful, whether businesses, politicians or celebrities use to stifle media criticism. However, unlike the media academic journals and academics (well science ones anyway) can call upon very high quality evidence to support their arguments as a matter of routine.
    I think this is just another example of the CAM world being largely interested in protecting profits and members interests rather than concern for patients. Their critics scare them, whether or not that fear is grounded in dishonesty, they know their therapies are nonsense, or ignorance, they don’t know their therapies are nonsense, I am not sure. However, it is clear they use the conventions of the business world in their approach rather than the conventions of academia.

  4. Dr* T said,

    August 8, 2008 at 4:10 pm

    The ASA ruled back in April about a ex-Chiropractor calling himself a Dr. (Blogged here)

    It was “Dr” Christian Farthing at the Ideal Spine Centre in Canterbury. His website had this note:

    “Dr. Farthing is not a Chiropractor, Osteopath or Medical Doctor.”

    Doctor of Wellness, apparently, so that’s OK.

  5. manigen said,

    August 8, 2008 at 5:11 pm

    It’s just so stupid. Not only are the NZCA showing themselves to be unpleasent bullys, but they’ve kicked off the streisand effect. Chances are nobody here would ever have read the original article in the New Zealand Medical Journal, but now we’ve all had a look. By attempting to supress criticism, they’ve caused it to go global.

  6. Jamie Horder said,

    August 8, 2008 at 5:34 pm

    They’ve shot themselves in the foot. Or as they would say, given themselves a lower spinal subluxation.

  7. muscleman said,

    August 8, 2008 at 7:11 pm

    Also the laws of slander and defamation are not as litigant friendly in NZ as they are here in Blighty. So the chances of the NZCA succeeding are exceedingly slim. There are also a lot of judges with some good common sense (vis the failure of the US to bully NZ into throwing the book at a certain hacker). I can see a judge throwing the book at the NZCA if they ever bully a lawyer into taking it to court.

  8. jonathanhearsey said,

    August 9, 2008 at 12:22 pm

    ‘But the time has come for practitioners with any common sense to distance themselves rapidly from this kind of bullying behaviour, or watch their professions become a well-deserved mockery. Suing academic journals. FFS.’

    Dr. G – It’s the True Believer cr@p all over again.

    Remember, I was threatened by an anon. ‘professional’ for speaking out against CAMs on my own blog.

    There ARE some quacks with common sense – some that don’t pretend to play Doctor. Sadly, there are only a few!

    Keep it up,

    JH

    jonathanhearsey.com

  9. David Colquhoun said,

    August 9, 2008 at 9:19 pm

    Thanks Ben, for rushing to the rescue. Lawyers always make one nervous.

    Just one little correction though. I have never asked for alternative therapists to be banned, and I’m not aware of any letter to the Times that asked for that to be done.

    All I have ever asked is that the NHS should avoid, and the government should not endorse unproven and disproved treatments, as far as possible. And that BSc degrees should bear some relation to science. I would also like to see existing laws on false advertising and unfair trading enforced a bit more vigorously. None of that amounts to a ban by any stretch of the imagination,

    Michael Baum and I have also proposed that the NHS might employ people who might be called something like “complemantary health workers in supportive and palliative care”. They could do the useful things that the ‘spiritual healers’ of UCLH do, but cutting out the gobbledygook and magic.

    That doesn’t sound like much of a disagreement to me.

  10. jonathanhearsey said,

    August 9, 2008 at 11:00 pm

    I’m going to add something further here – and, in doing so, I’m going to be skating on very thin ice. As an osteopath (small ‘o’, and a Mr. to boot – but I NEVER let people think I’m a surgeon!!!) I’m tarred with the same brush as the chiropractors, but only in the same way that a manipulative physiotherapist is. Broadly speaking, on a VA scale you have non-manipulative physio in the left corner, chiroqaucktors in the right and I fit somewhere in the middle.

    For the NHS I have a strict brief where I practise only where (limited) evidence says I might be a reasonable alternative (see my blog). This has worked well for the last 12 years.

    I agree with DC and MB when they suggest that ‘the NHS might employ people who might be called something like “complemantary health workers in supportive and palliative care”’. This makes sense – but anyone that is employed in this way must be trained in the way that Extended Scope Practitioners are trained.

    To me, science is like the debating society at school – you argue during the lunch-break but are friends when the bell goes for double maths. Chiropractors in NZ are not playing the game – they don’t want to debate, they just want to steel your curly-whirly and give you a wedgy. Why? Because they can.

    JH

  11. Ben Goldacre said,

    August 10, 2008 at 12:15 am

    hi david, soz, i meant banned from the nhs. i guess you’re a bit more hardline than me on these jokers, but i think also both of our views are a little fluid and conflicted on it too, which is as it should be.

    the quest for an ethical way to use quackery goes on, but bullies like this certainly reduce everyone’s enthusiasm for the project. my view – espoused at length in a placebo two-parter on radio 4 in a week or so – is that mainstream medicine (docs, nurses, physios, health care assistants, OTs etc) should use the best of the evidence from the world of placebo research to enhance benefits from treatments that do actually do stuff.

  12. gadgeezer said,

    August 10, 2008 at 2:16 am

    This combines the radio programme on placebo and the UCLan story but – would you feel differently if UCLan and other universities were to offer a BSc in Placebo Studies – or an MSc (I have no idea of the content so don’t know which would be more ‘feasible’)?

    I suppose that placebo studies would have to be grounded in plausible narratives and an ability to assess the data but if appraisal of CAM was in there, it might be interesting.

  13. puzzlebobble said,

    August 10, 2008 at 12:14 pm

    I’d be nervous about intentionally enhancing the placebo effect. I understand that you are only referring to an additional effect on ‘treatments which actually do stuff’ but, given that medics have to discuss life n’ death stuff etc. with patients, couldn’t the loss of patient trust outweigh any benefits from the placebo effect?
    Also the placebo effect will have an organic mechanism which we could investigate. Greater understanding might allow us to manipulate the system pharmacologically etc.
    But then I’m forced to ask ‘if manipulating the placebo system pharmacologically is ethically any different then manipulating it psychologically?….which causes my brain to hurt.
    I guess a fundamental question is; ‘if we are to use the placebo effect are we going to be honest to patients and say, for example, “this drug actually works but it also has an added effect as a placebo, especially when it is the colour blue”?
    I’m not sure I can logically or ethically differentiate between a ‘pure’ placebo and a placebo intentionally ‘added’ to an effective treatment unless you do propose to inform patients. A ‘pure’ placebo might well have much less of a placebo effect than an ‘added’ placebo in informed patients.
    I guess that there might also be positive feedback loops between real effect and placebo effect but I don’t see how this ethically allows one to differentiate between ‘pure’ and ‘added’ placebos.

  14. used to be jdc said,

    August 10, 2008 at 5:15 pm

    @Puzzlebobble:

    I guess a fundamental question is; ‘if we are to use the placebo effect are we going to be honest to patients and say, for example, “this drug actually works but it also has an added effect as a placebo, especially when it is the colour blue”?

    Maybe we can be honest about placebos:
    Lee Crandall Park – An Exploration of Neurotic Patients’ Responses to Placebo When Its Inert Content Is Disclosed

    ["The primary finding is that patients can be willing to take placebo and can improve despite disclosure of the inert content of the pills; belief in pill as drug was not a requirement for improvement."]

  15. puzzlebobble said,

    August 10, 2008 at 7:47 pm

    @used to be jdc
    Thanks for the link. I did wonder if there had been any trials looking at ‘open’ placebos but found it hard to find one on medline. Probably due to my inability to think of good search terms.

    It’s very interesting but given the study design I think it’s hard to interpret. I particularly didn’t like the fact that they stopped all other medications which is my experience often makes patients feel better in the short term. The lack of a control group compounds this (eg. a hidden placebo group).

    Time to see if anything has referenced this paper.

  16. puzzlebobble said,

    August 10, 2008 at 8:52 pm

    The only other trial I’ve found so far looking at an open placebo is:
    Effets de la prescription d’un placebo « annoncé »
    Which I would have had a go at, even though it is in french, but I haven’t got access. Sod. If anyone has and feels like helping me out that’d be great.

  17. puzzlebobble said,

    August 11, 2008 at 8:20 pm

    @William Levack
    In the paper ‘used to be jdc’ discovered they said this:
    “Mr. Doe, at the intake conference we discussed your problems and your condition, and it was decided to consider further the possibility and the need of treatment for you before we make a final recommendation next week. Meanwhile, we have a week between now and your next appointment, and we would like to do something to give you some relief from your symptoms. Many different kinds of tranquilizers and similar pills have been used for conditions such as yours, and many of them have helped. Many people with your kind of condition have also been helped by what are sometimes called “sugar pills,” and we feel that a so-called sugar pill may help you, too. Do you know what a sugar pill is? A sugar pill is a pill with no medicine in it at all. I think this pill will help you as it has helped so many others. Are you willing to try this pill?”

    I still don’t think it would be right to intentionally manipulate the placebo effect without being honest and informing patients.

    Although I’d be very careful about what I defined as a placebo effect. Something such as an unhurried chat with a sympathetic doctor I wouldn’t call a placebo. Changing the colour of the pill to suit the condition I would. I admit there’s a big grey area in-between and trying to define a placebo gets me tangled in knots.

  18. used to be jdc said,

    August 13, 2008 at 12:01 pm

    Sorry – I tried to link to All Bow… last night but my comment seems to have got trapped in the spam filter due to all the links and html I used. The Lee Crandall Park paper is linked from this piece, as is Walsh 2002, which refers to the response to placebo in published trials of antidepressant medication for MDD increasing over time.

    Cheers,
    jdc

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