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Oct 15 2013

Folk remedies with lashings of meridian

Massimo Pigliucci and Maarten Boudry on why pseudoscience is dangerous. (I’m reading their edited collection The Philosophy of Pseudoscience.)

There is no question that some folk remedies do work. The active ingredient of aspirin, for example, is derived from willow bark, which had been known to have beneficial effects since the time of Hippocrates. There is also no mystery about how this happens: people have more or less randomly tried solutions to their health problems for millennia, sometimes stumbling upon something useful. What makes the use of aspirin “scientific,” however, is that we have validated its effectiveness through properly controlled trials, isolated the active ingredient, and understood the biochemical pathways through which it has its effects (it suppresses the production of prostaglandins and thromboxanes by way of interference with the enzyme cyclooxygenase, just in case you were curious).

Asma’s example of Chinese medicine’s claims about the existence of “Qi” energy, channeled through the human body by way of “meridians,” though, is a different matter. This sounds scientific, because it uses arcane jargon that gives the impression of articulating explanatory principles. But there is no way to test the existence of Qi and associated meridians, or to establish a viable research program based on those concepts, for the simple reason that talk of Qi and meridians only looks substantive, but it isn’t even in the ballpark of an empirically verifiable theory.

Well maybe just by talking about Qi and meridians, people make them effective. In a meridian Qi-esque kind of way.

I kid. I don’t believe in the magical powers of jargon. Jargon deployed that way makes me want to smack things.

In terms of empirical results, there are strong indications that acupuncture is effective for reducing chronic pain and nausea, but sham therapy, where needles are applied at random places, or are not even pierced through the skin, turn out to be equally effective…

Placebo effect, in other words. Speaking of placebo effect, wouldn’t you think it wouldn’t work if you know it’s a placebo? I use diphenhydramine as a sleeping pill often, and the other day I Googled it out of curiosity, and found that its effect wears off after three days and then it’s just a placebo. Ok, except it didn’t make any difference knowing that. I loudly announce that I’m taking a placebo now, just so that everyone including the pink pill will know I know it’s a placebo – but I go to sleep anyway. Very weird.

Philosophers of science have long recognized that there is nothing wrong with positing unobservable entities per se, it’s a question of what work such entities actually do within a given theoretical-empirical framework. Qi and meridians don’t seem to do any, and that doesn’t seem to bother supporters and practitioners of Chinese medicine. But it ought to.

But meridian is such a pretty name.

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  1. 1
    sc_770d159609e0f8deaa72849e3731a29d

    You’re not a big enough sample to be reliable, but have you tried taking a genuinely inert placebo to see what happens? Also, if you “use diphenhydramine as a sleeping pill often”, rather than always, won’t its effects depend on how long it takes for the wearing off of the sedative effect to wear off?

  2. 2
    Claire Ramsey

    I could help you out by setting up an n=1 experiment (“trick”) that might shed light. I will tell you that I have special sleep inducing toothpaste. And as a special touch I will use chicken-flavored dog toothpaste. And crush up a diphenhydramine in some doses and leave it out of others. You will wear yourself out fighting to not have to use the canine toothpaste and have an easy time falling asleep!

  3. 3
    John Phillips, FCD

    Quite some time ago I read an article by Ben Goldacre about research by Prof Ted Kaptchuk and his team from the Harvard Medical School’s Osher Research Center. They found that when compared to a control group that received no treatment at all, they got statistically significant results when the test subjects being ‘treated’ with placebos had it emphasised beforehand that they were being treated with a placebo with an explanation of what a placebo was. The paper was published in PLOS ONE and if you Google the phrase Placebos without deception it should be the first result.

  4. 4
    chrislawson

    John @3: your Google-fu is strong. Excellent paper, by the way.

  5. 5
    chrislawson

    Hi Ophelia,

    With due respect, I am becoming increasingly frustrated at seeing this argument trotted out repeatedly against acupuncture. I’m just about the strongest possible advocate for evidence-based medicine you can find and I think the vast majority of “alternative” medicine is bunkum, often dangerously so, but this particular argument has broken legs and ought to be taken out the back of the stables and put out of its misery.

    What is true: there is a lot of published evidence favouring acupuncture, but most of it is very poor quality. The traditional Chinese theory behind acupuncture — that of Qi and meridians — is utterly wrong. We know this because (1) there are no known anatomical structures that follow the distribution of meridians, (2) even if some future scientist astonishes us by finding the appropriate structures, they certainly won’t be physically capable of moving air (which is what Qi means; modern quasi-scientific “spirit” or “energy” apologetics can be ignored) around the body, and (3) there are now several studies showing that sham acupuncture, that is random needling, is exactly as effective as traditional acupuncture, thus demonstrating that the traditional meridians have nothing to do with the medicinal effect of acupuncture. And yes, Chinese medical practitioners ought to be ashamed of themselves for sticking to a patently untrue theory. And yes, Asma’s pseudoscientific defence of Chinese medical theory deserves to be pilloried (and I’m pleased that Pigliucci and Boudry took it on). This much I agree with.

    But…there is a big gaping hole at the center of this particular epistemic argument. Where Pigliucci and Boudry go wrong is in assuming that the explanatory framework is what makes a treatment evidence-based. It’s not. What makes medicine evidence-based is the strength of the evidence for a positive benefit. Counter-intuitively, I try to teach my medical students that they should be *distrustful* of theoretical explanations for why they should use a treatment. This kind of explanation is strongly favoured by pharmaceutical company marketing departments because they know full well that providing an explanation for why something works makes people more likely to believe they work. This line of thinking (not always due to pharmcos) has led to medical disasters in the past, including the use of flecainide routinely post-MI which probably caused upwards of 50,000 avoidable deaths per year in the US while it was in favour…purely because cardiologists thought they understood its mechanism of action well enough in prevent arrhythmias. In reality, when they tested it against the outcome that mattered, not arrhythmia frequency but deaths, flecainide was killing about 5% of the people it was given to post-infarct.

    The flip-side is also important: there are many treatments in Western medicine that have poorly-understood mechanisms of action. Paracetamol (acetaminophen to Americans) is a case in point: a very effective analgesic sold by the millions of doses every day around the world, with a still only partially-unravelled mechanism. Even more surprising, we don’t really understand how general anaesthetics work.

    Anyone who says “this is scientific because we understand how it works” is missing the point. Explanatory frameworks are important not because they prove what works (otherwise we’d still be treating ancient Greek humours), and even wrong theories can be useful (we can use Newtonian physics and ignore special relativity for most daily applications), but they’re important because they help us work out fruitful avenues for future research. There is an infinite number of possible experiments that can be performed. Explanatory frameworks help us direct our energies towards experiments that are likely to give us interesting answers. And in medicine, they help us weigh up risks and benefits when we don’t have as much evidence as we would like (which is often). That’s the real problem with meridians and Qi. It’s not just that the theory is wrong, it’s that the theory is so broken that it’s useless for designing future experiments or for deciding whether to use acupuncture for a given patient.

  6. 6
    chrislawson

    Oh, and contra Pigliucci and Boudry, the mechanism of aspirin is not nearly as well understood as they present it. It’s certainly true that aspirin alters cyclo-oxygenase metabolism and that probably explains its anti-pyretic and analgesic action, but we still don’t understand why it can trigger the very nasty Reye’s syndrome, don’t know how important its effect on DNA transcription is, don’t know why some people develop allergic reactions to aspirin and others don’t, and so on. When I read their piece on how well we understand aspirin, it reminds me of A. A. Michelson’s 1894 opinion that science was so well known it was going to be about the “sixth place of decimals” from then on.

  7. 7
    Ophelia Benson

    Wo, that’s interesting about the placebo study – interesting and deeply weird. Or maybe not. Maybe it’s just the same mechanism – “we know a placebo can work, so it’s a placebo, so it can work.”

    I also find it endlessly hilarious. I’ve mentioned before the skit on Spank the Pony in which a doctor says “Ima give you a placebo for that” and the patient says “it won’t work if you tell me it’s a placebo!!1″ and the doctor is surprised and puzzled.

    Yes Claire please do that!

  8. 8
    anne mariehovgaard

    chrislawson @ 5:

    <blockquote cite="Anyone who says “this is scientific because we understand how it works” is missing the point.</blockquote cite="
    Well, yes, since the point here is that "this is UNscientific because people claim to understand how it works, but 1. science shows that their explanation is wrong and 2. there's no good evidence that it actually does work." If there's a lot of evidence that it works way better than a placebo, but we're not sure why, we should keep using it (unless there's some other reason not to) but also keep doing research. If, like with acupuncture, the evidence strongly suggests it's just an elaborate placebo, we should stop using it. Find an equally impressive serious-medical-treatment-y placebo with no risk of infection or other injury, instead, if you feel you need it. And try not to deceive people.

  1. 9
    Guest post: the real reason explanatory frameworks matter » Butterflies and Wheels

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