Answering Critics

Answering Our Critics

Some people don’t like what we have to say on Science-Based Medicine. Some attack specific points while others attack our whole approach. Every mention of complementary and alternative medicine (CAM) elicits protests in the Comments section from “true believer” users and practitioners of CAM. Every mention of a treatment that has been disproven or has not been properly tested elicits testimonials from people who claim to have experienced miraculous benefits from that treatment.

This article, by Harriet Hall, and posted to Science-Based Medicine, beautifully responds to a number of the numerous criticisms leveled at CAMCheck. As she explains: “Our critics keep bringing up the same old memes, and it occurred to me that rather than try to answer them each time, it might be useful to list those criticisms and answer them here.” (This is part one. Part two continues here.) In the case of CamCheck, we are not arguing for “Science-Based Medicine” but the subtle difference of “Evidence-based Medicine”, i.e., we want to see adequate proof!

“Fair comment” and defamation

Our opinions are without malice, not extreme, unjust, unbalanced, exaggerated nor prejudiced but based on supporting evidence for our assertions – alternatively, demonstrating a lack of evidence for claims being made.  The facts and/or rationale for our assertions accompany our postings. Although these opinions may appear harsh, they are indeed true. Could these comments appear to be defamatory?

The defense against an action of defamation would be that the statement is true and for the public benefit, or that it is fair comment on a matter of public interest.

Your Rights describes “fair comment” as such:

“If a defendant can prove that the defamatory statement is an expression of opinion on a matter of public interest and not a statement of fact, he or she can rely on the defence of fair comment.”

“The courts have said that whenever a matter is such as to affect people at large, so that they may be legitimately interested in, or concerned at, what is going on or what may happen to them or to others, then it is a matter of public interest on which everyone is entitled to make fair comment.”

“The comment must be based on true facts which are either contained in the publication or are sufficiently referred to. It is for the defendant to prove that the underlying facts are true. If he or she is unable to do so, then the defence will fail. As with justification, the defendant does not to have to prove the truth of every fact provided the comment was fair in relation to those facts which are proved.”

Is there a local South African precedent?

“The fact that a defamatory statement is true and that its publication was for the public benefit constitutes a complete defence.”
Du Bois (Editor) Wille’s Principles of South African Law (9th editionpages 1177-8.

More recent judgments of the Constitutional Court:

“The common law requires the defendant to establish, once the plaintiff has proved the publication of defamatory statement affecting the plaintiff, that the publication was lawful because the contents of the statement were true and in the public benefit.”
Khumalo v Holomisa 2002 (5) SA 401 (CC) at para 37 per O’Regan J

Criticism was protected even if extreme, unjust, unbalanced, exaggerated and prejudiced so long as it expresses an honestly-held opinion, without malice, on a matter of public interest on facts that were true.
http://www.news24.com/SouthAfrica/News/Paper-wins-main-McBride-appeal-20110408

Prof Pierre de Vos wrote an excellent piece about “defamation” for the Daily Maverick. Two interesting and relevant paragraphs are:

“Secondly, would the court extend this defence to people who are not full-time journalists and who publish news reports or opinions on blogs or community-based websites like GroundUp? And what about bloggers and other opinion makers who post opinions about current events on Twitter or Facebook? I can see no reason why the platform used for the reporting should make a difference to the rule, and I would argue that those who publish news reports and opinion pieces on blogs or websites should also be allowed to invoke the reasonableness defence, because these reports and opinion pieces fulfil the same function as those published on traditional media platforms.”,

and,

“When you sue somebody for defamation, you usually make things worse by attracting attention to the offensive comment. When you do not laugh off a slightly unhinged comment like that, your response sends a signal that the comment really hurt you and might actually be close to the truth. And if you then threaten to sue or actually sue, you might well further harm any reputation you might have left – instead of protecting it from harm. More politicians and public figures should keep this in mind.”

Prof de Vos has elaborated on defamation in the blog, ConstitutionallySpeaking.co.za:

If you want to avoid liability for making such prima facie defamatory statements, you will have to raise a defence which either shows that the statements were not made intentionally or were not unlawful. As the Constitutional Court explained in Khumalo v Holomisa:

“Although not a closed list, the most commonly raised defences to rebut unlawfulness are that the publication was true and in the public benefit; that the publication constituted fair comment and that the publication was made on a privileged occasion.”

This means you will not be liable for defamation if you can show to a court that what you had said was both true and was on a matter that was in the public interest.

Recently (3/12/2017), in response to a letter from Prof Tim Noakes’ lawyer, Prof de Vos, had the following to say:

“Second, as you well know, it is not unlawful to express an ‘honest, genuine (though possibly exaggerated or prejudiced) expression of opinion relevant to the facts upon which it was based (The Citizen 1978 (Pty) Ltd and Others v McBride). As Cameron J remarked in that case about the defence of fair comment:

‘So to dub the defence ‘fair comment’ is misleading. If, to be protected, comment has to be ‘fair’, the law would require expressions of opinion on matters of fact to be just, equitable, reasonable, level-headed and balanced. That is not so. An important rationale for the defence of protected or ‘fair’ comment is to ensure that divergent views are aired in public and subjected to scrutiny and debate. Through open contest, these views may be challenged in argument. By contrast, if views we consider wrong-headed and unacceptable are repressed, they may never be exposed as unpersuasive. Untrammelled debate enhances truth-finding and enables us to scrutinise political argument and deliberate social values.”

All CamCheck’s postings are factual and claims and statements can be supported with evidence. 

 

Placebo effect

This often comes up – how do we know whether something is a real effect or simply a placebo response?

In a British study, 835 women who regularly used analgesics for headache were randomly assigned to one of four groups (43). One group received aspirin labeled with a widely advertised brand name (“one of the most popular” analgesics in the United Kingdom that had been “widely available for many years and supported by extensive advertising”). The other groups received the same aspirin in a plain package, placebo marked with the same widely advertised brand name, or unmarked placebo. In this study, branded aspirin worked better than unbranded aspirin, which worked better than branded placebo, which worked better than unbranded placebo. Among 435 headaches reported by branded placebo users, 64% were reported as improved 1 hour after pill administration compared with only 45% of the 410 headaches reported as improved among the unbranded placebo users. Aspirin relieves headaches, but so does the knowledge that the pills you are taking are “good” ones.
Moerman DE, Jonas WB. Deconstructing the placebo effect and finding the meaning response. Ann Intern Med. 2002 Mar 19;136(6):471-6.
 
A study on headache pain relief conducted in England by Braithwaite and Cooper shows the placebo effect of brand names. In this experiment, there were four groups. Group A received a placebo labeled analgesic, group B received a placebo labeled with a brand name, group C received aspirin labeled analgesic, and group D received aspirin labeled with a brand name. The results showed that aspirin worked better than the placebos. However in comparing groups A and B, which both received placebos, the placebos labeled with a brand name greatly surpasses the effects of the placebo labeled analgesic. Branthwaite A, Cooper P. Analgesic effects of branding in treatment of headaches. Br Med J (Clin Res Ed). 1981 May 16;282(6276):1576-8.
 
In the study above, TABLE II-Pain relief after one hour for all headaches in all groups (results expressed as numbers (on) of headaches) is most interesting.
AspirinStudy  

Notice how of the 209 patients in Group A who took the unbranded placebo, 111 said that they were completely better and in Group B, 134 of those taking the branded placebo were completely better. In other words, although the “aspirin” they took was only a placebo, they felt “completely better” – this is a good example of a placebo effect.

Read more about the placebo effect here: Placebo effect 

 
If the placebo effect is beneficial – is that that not good enough?
We agree with Dr Harriet Hall, who wrote:
I would argue that we don’t just want our patients to think they are better, we want them to actually be better. A study that illustrates that principle has been discussed on this blog before.
She gives the following example commenting on this study:
“A group of patients using an effective albuterol asthma inhaler was compared to 2 placebo groups (a placebo inhaler group and a sham acupuncture group), and to a group that got no treatment at all. Patients reported the same relief of symptoms with each of the two placebo controls as with the albuterol inhaler; all three groups reported feeling significantly better than the no-treatment group. It could be argued that placebos are an effective treatment for the subjective symptoms of asthma.But when they used an objective measure, improvement in lung function, airflow only increased in the albuterol group. The placebo groups were indistinguishable from the no-treatment group. So here you have patients who feel better and think they are better but who aren’t actually better, who might not recognize the severity of an asthma attack in time to get to the ER and avoid a fatal outcome. As Peter Lipson said, we have effective, lifesaving treatments for asthma, and treating an asthma attack with a placebo is folly.”
Update 28 March 2015: A superb overview of the placebo effect authored by Dr Harriet Hall
Another consideration, close to a “placebo” response and that one has to consider is “regression to the mean” or “confirmation bias” (below). 
Regression to the Mean
Regression to the mean is a widespread statistical phenomenon with potentially serious implications for health care. It can result in wrongly concluding that an effect is due to treatment when it is due to chance. Ignorance of the problem will lead to errors in decision making.
Morton V, Torgerson DJ. Effect of regression to the mean on decision making in health care. BMJ. 2003 May 17;326(7398):1083-4.
Confirmation bias
Confirmation bias is the tendency for people to only seek out information that conforms to their pre-existing view points, and subsequently ignore information that goes against them. Confirmation bias (or confirmatory bias) is a tendency interpret information in a way that confirms one’s preconceptions. The effect is stronger for emotionally charged issues and for deeply entrenched beliefs. 
Causality illusion
Assigning a causal relationship to two events simply because they happened one after the other: the “illusion of causality.” An excellent overview of this illusion.

Hawthorne effect
Subjects may change their usual behavior just because they are participating in a study, and this can lead to overestimating the effects of treatment, particularly in the control group. [1]

Simpson’s paradox
When unrecognized determining factors (“confounders”) influence the data, the overall results of a study can be completely changed by analysis of sub-groups. [Translator’s note: another way of saying this is that a trend that appears in different groups of data can disappear or reverse when the groups are combined.] [1]

The Will Rogers phenomenon
Improved diagnostic methods that artificially increase the prevalence of a disease can improve the apparent prognosis of a patient without the measurement parameters having been changed. [Translator’s note: If cancers are diagnosed earlier but there is no change the time of death, the survival time will appear to have increased. The name comes from a Will Rogers quotation: “When the Okies left Oklahoma and moved to California, they raised the average intelligence level in both states.“] [1]

Logical fallacies
A list of a wide range of logical fallacies that scam artists, pseudoscientists, and alternative medicine practitioners use in order to dupe you.
A logical fallacy is usually what has happened when someone is wrong about something. It’s a flaw in reasoning. They’re like tricks or illusions of thought, and they’re often very sneakily used by politicians and the media to fool people. Don’t be fooled! This website and poster have been designed to help you identify and call out dodgy logic wherever it may raise its ugly, incoherent head.” yourlogicalfallacyis.com
Orthodox/Mainstream doctors are not holistic or out to make money
This section includes articles pointing out the nonsense spread by “alternative” health professionals (Integrative Medicine / Functional Medicine) that claim that their approach is better for patients.
Media Guide to Skepticism
“To provide a clear, easy-to-read guide about the “Skeptical” viewpoint as subscribed to by many who might call themselves Skeptics or critical thinkers”
A great overview of what sceptics are published at Doubtfulnews.
References:
1. Kleist, P. (2006). “Quatre effets, phénomènes et paradoxes de la médecine. Leur signification et leurs racines historiques [PDF]. Forum Med Suisse; 6 :1023–1027.
The Debunking Handbook by John Cook and Stephan Lewandowsky [1]
 
Debunking myths is problematic. Unless great care is taken, any effort to debunk misinformation can inadvertently reinforce the very myths one seeks to correct. To avoid these “backfire effects”, an effective debunking requires three major elements. First, the refutation must focus on core facts rather than the myth to avoid the misinformation becoming more familiar. Second, any mention of a myth should be preceded by explicit warnings to notify the reader that the upcoming information is false. Finally, the refutation should include an alternative explanation that accounts for important qualities in the original misinformation.
1. Cook, J., Lewandowsky, S. (2011), The Debunking Handbook. St. Lucia, Australia: University of Queensland. November 5. ISBN 978-0-646-56812-6. [http://sks.to/debunk]
Motivated Reasoning
“A man with a conviction is a hard man to change,” Festinger, Henry Riecken, and Stanley Schacter wrote in When Prophecy Fails, their 1957 book about this study. “Tell him you disagree and he turns away. Show him facts or figures and he questions your sources. Appeal to logic and he fails to see your point … Suppose that he is presented with evidence, unequivocal and undeniable evidence, that his belief is wrong: what will happen? The individual will frequently emerge, not only unshaken, but even more convinced of the truth of his beliefs than ever before.”
An excellent article published in The Atlantic regarding dealing with conflicting evidence as a way of reducing the discomfort of dissonance, and as part of a set of behaviors known in the psychology literature as “motivated reasoning.”
How to counter the circus of pseudoscience
An excellent article by Lisa Pryor in the New York Times, points out how orthodox health professionals are taught to consider all facts, consider emerging evidence, and a change in factors. These result in constant doubt, readjustment of opinion based on new facts, and constant re-evaluation of your opinion. How this compares with alternative medicine practitioners who have no doubt, only certainly, in spite of little training or expertise.