By Gary Null and Helen Buyniski
In an attempted rebuttal of Death by Medicine, by Drs. Gary Null, Martin Feldman, Debora Rasio, and Carolyn Dean, self-styled “SkepDoc” Harriet Hall accidentally exposes the core flaws of so-called “science-based medicine” (SBM) while leaving the authors’ argument stronger than ever. Hall’s piece is more of a partisan diatribe than a scientific argument, bereft of facts and figures and packed with empty generalities, but most importantly it relies on a flawed model of medicine in which treatment is the preferred paradigm and prevention is at best an afterthought. Modern medicine waits for the patient to become diseased – to manifest a clinical symptom – before attempting to treat that symptom, using drugs or surgery or another procedure. If the patient recovers, the intervention is given all the credit, even if the patient may have made positive life changes after the ‘wake-up call’ of getting sick.
The prevailing model of oncology, for example, holds that if a patient goes into remission, credit goes to the treatment – chemo, radiation, surgery, or a combination thereof. No credit is given to lifestyle modifications that have been scientifically proven to have anti-carcinogenic effects – eating a healthy vegan diet full of fresh fruits and vegetables; exercising frequently; taking herbs and supplements like vitamin C and D, quercetin, and CoQ10; and cutting out smoking and drinking and other unhealthy vices – as these are not considered the domain of medicine and therefore not relevant to the disease model, even if the patient adopted these behaviors specifically for their health benefits. If the patient does not recover, well, medicine isn’t perfect, and maybe the patient didn’t follow their instructions to the letter – it’s not the chemo’s fault.
The resulting statistics are hopelessly biased in favor of any medical intervention, even though – by that logic – patients who have a procedure, seem to recover in the hospital, but die on returning home are generally assigned a cause of death unrelated to the procedure. Even with these skewed statistics, JAMA and BMJ have both admitted iatrogenic is the third leading cause of death in the US[1, 2], and the writers of Death by Medicine arrived at their more sobering statistic by adding the total numbers of deaths caused by hospital-acquired infections and bedsores to that already hefty total. If they were to count the vast number of patients who survive a hospital procedure only to go home and die of related complications, the number would surely be higher. Yet everyone who walks out of a cancer ward alive is chalked up as a victory for that treatment.
The multifactorial nature of individual health is routinely ignored as too complex for the binary nature of modern medicine, which stops when the doctor can no longer measure a symptom. By the standard of the Skeptics, you’re healthy…until you’re sick. The pathogenesis of illness is enormously complex, with cells altered over 10,000 times a day. If the human body has 75 trillion cells and these are all in a constant state of flux based on everything we do or do not do, it’s completely absurd to simplify “cancer” to the presence or absence of detectable tumors. Diet and lifestyle are not even considered in the medical model until the patient manifests a clinical symptom. Sickness is prioritized over wellness – and it’s much more profitable to treat a disease than to prevent it from happening in the first place. Indeed, Harvard Medical School’s Dr. Marcia Angell, former editor-in-chief of the New England Journal of Medicine, became a harsh critic of the role money plays in medicine. After 20 years at NEJM, where she saw firsthand the huge sums paid by drug companies to physicians to run studies whose results could not be replicated, she wrote, “It is simply no longer possible to believe much of the clinical research that is published, or to rely on the judgment of trusted physicians or authoritative medical guidelines.”
Harriet Hall, a retired family physician who now writes about “questionable medical practices,” attempted a drive-by debunking of Death by Medicine, perhaps not realizing how much serious scholarship went into the book. The authors – MDs and PhDs with years of clinical and research experience – spent five years sifting through peer-reviewed medical literature to come up with the statistics that definitively show iatrogenic causes are the primary killer of Americans. But their goal was not to condemn medicine entirely, as Hall claims in her post. Indeed, for emergencies, western medicine is unparalleled. In the case of a heart attack, stroke, severed limb, or gunshot wound, the system works fabulously. But acute care comprises only 10 percent of medical procedures.
Hall dismisses the authors’ numbers repeatedly and without offering contradicting statistics of her own, indicating she lacks factual ammunition for her claims. Indeed, she tacitly admits as much from the outset, first claiming “Most of their numbers are wrong,” then “They are based on extrapolations,” and finally “Even when they are more or less accurate they are misleading.” That’s quite a journey in just three sentences, ultimately acknowledging the figures – culled from the most prestigious peer-reviewed scientific journals –are “more or less accurate.” She attempts to dismiss adverse drug reactions (ADRs) as “minor annoyances,” even though the Lancet takes them quite seriously, defining the term as “an appreciably harmful or unpleasant reaction, resulting from an intervention related to the use of a medicinal product, which predicts hazard from future administration and warrants prevention or specific treatment, or alteration of the dosage regimen, or withdrawal of the product.” By insisting that the harm from ADRs pales in comparison to the benefits of the drugs, she only betrays her ignorance of medical terminology, and once again assumes the mantle of medical arrogance that insists all patient improvements must be credited to the treatment.
Much of Hall’s screed is mere hypothesizing and rhetorical games, an effort to place the burden of proof on the writers (the writers who wrote a book full of statistics from peer-reviewed literature, instead of a blog post lacking a single quantifiable fact). People who developed iatrogenic infections in the hospital may, as she writes, have died had they not gone to the hospital as well, but so might patients who seemed to recover after surgery die in their beds the following day due to unforeseen complications from the treatment. There is no way to quantify either possibility, and thus they are not included in the statistics. Otherwise, the iatrogenic death toll would no doubt skyrocket! The authors are not claiming a higher cure rate from “avoiding hospitals.” The task of the modern medical professional is to cure the patient, and if they cannot do that, to at least avoid causing harm. The authors make a strong case that medicine should attempt to prevent disease before the patient needs curing.
Hall admits that unnecessary antibiotics, procedures, and hospitalizations happen, but claims the numbers in the book are inflated – once again, without a single example or link to a contradicting statistic, perhaps hoping we’ll just take her word for it. She bemoans the authors’ failure to “even try to estimate how many of those ‘unnecessary’ treatments led to deaths” but had they done so would doubtless be criticizing them for using unscientific estimates. Similarly, she demands the authors transpose themselves into the past to discern how many iatrogenic deaths would have occurred in an era of pre-modern medicine – once again forgetting that the authors are not defending pre-modern medicine, and conjuring up the specter of leeches and bloodletting is a red herring.
Dismissing bedsores and malnutrition as the mere ‘cost of doing business’ for modern nursing homes, Hall writes, “I wonder how the incidence of those things compares between home care by untrained family members and science-based care in a well-run institution.” Her ‘wonder’ is a convenient way to avoid making a factually-unfounded statement, and she seems to have lost faith in her own argument when she complains that “doctor-bashers” argue alternative medicine is safer than allopathic: “I suppose not treating at all would be safer still.” After quibbling Clinton-style over the definition of the word “safe,” she claims the patient’s true desire is to know the risk/benefit ratio of any treatment – a perfectly understandable request, yet one not honored by most practitioners of “science-based medicine,” who often treat the patient as an ignorant lump to be cut into and experimented upon at will by themselves, the Chosen Ones of medicine. “Informed consent,” such as it is, is generally extracted via a hurried signature on an impenetrably dense contract, dashed off as the patient is wheeled into the operating room. Indeed, is it any wonder doctors make so many mistakes given the miniscule amount of time they actually spend with patients?
Again, Hall scores a point for her opponents when she admits their statistics come from peer-reviewed medical literature, but attempts to cast it as a point for “science-based medicine” by claiming only her “side” is capable of such transparency. Perhaps she has not read the hundreds of thousands of articles on alternative medicine published in the same peer-reviewed journals, studies the Skeptics prefer to ignore.
Finally, it becomes clear that she has not actually read Death by Medicine when she accuses the authors of “condemning all of modern medicine” – which they do not do, anywhere in the book. The whole point of the book (and she could have gotten this by skimming the introduction, so there’s really no excuse) is as a starting point for the medical profession to make meaningful reforms. That they have failed to do so and instead choose to criticize those who point out their flaws indicates that we need Death by Medicine now more than ever. Proponents of “science-based medicine” assume they are infallible, donning modern-day priests’ garments when they put on their lab coats and blaming all errors on the patient. Their logic is airtight only because it is tautological – I am a Doctor, therefore I am Omniscient, therefore I cannot be wrong, therefore if something is wrong it is not because of my actions. Their hubris is literally killing people. If medicine is to take credit for its successes, it must also take credit for its failures, as much as it would like to pass the buck and blame the 600,000 cancer patients who die despite following their doctors’ orders every year, or the psychiatric cases who are more likely to attempt suicide when they take the antidepressants prescribed to them[7,8,9].
Hall concludes with a childish thought-experiment: “If the doctor-bashers want to play statistics, how about comparing death rates with modern scientific medicine to death rates with alternative medicine and death rates with no medicine at all. That might really be interesting!” Indeed it would, except that refusing treatment to sick patients is considered malpractice, and no ethical doctor would perform such an experiment. She ultimately blames “a failure to use medicine” for the lion’s share of patient deaths, absolving herself and her fellow Skeptics, keepers of the only correct interpretation of Medical Dogma. She calls out patients who “don’t follow preventive guidelines” (after spending the entire piece defending drugs and surgery, this is the first time “prevention” is mentioned), doctors “who don’t practice the best science-based medicine” (meaning when one of her patients dies, it’s their fault), and “all those who reject science-based medicine in favor of belief-based alternatives.” It’s interesting that she smears holistic alternatives as “belief-based” – Hall’s “rebuttal” of Death by Medicine is less an argument than a Skeptic sermon, and not a very compelling one at that.
1 Makary, M.A. et.al. “Medical error – the third leading cause of death in the US.” BMJ 2016;353:i2139 https://www.bmj.com/content/353/bmj.i2139.full
2 Starfield, B. “Is US Health Really the Best in the World?” JAMA. 2000;284(4):483-485. https://jamanetwork.com/journals/jama/article-abstract/192908?redirect=true
3 Thomas, Carolyn. “NEJM editor: “No longer possible to believe much of clinical research published.” The Ethical Nag. 9 Nov 2009. https://ethicalnag.org/2009/11/09/nejm-editor/
4 “Health and Economic Costs of Chronic Diseases.” Centers for Disease Control and Prevention. https://www.cdc.gov/chronicdisease/about/costs/index.htm Retrieved 20 Nov 2018
5 Edwards, I.R. “Adverse drug reactions: definitions, diagnosis, and management.” Lancet. 7 Oct 2000;356(9237):1255-9. https://www.ncbi.nlm.nih.gov/pubmed/11072960
6 Cancer Facts & Figures. American Cancer Society. 2017. https://www.cancer.org/research/cancer-facts-statistics/all-cancer-facts-figures/cancer-facts-figures-2017.html Retrieved 20 Nov 2018
8 Jureidini, J. “Restoring Study 329: efficacy and harms of paroxetine and imipramine in treatment of major depression in adolescence.” BMJ 2015;351:h4320 http://www.bmj.com/content/351/bmj.h4320
9 Healy, D. “Lines of evidence on the risks of suicide with selective serotonin reuptake inhibitors.” Psychother Psychosom. 2003 Mar-Apr;72(2):71-9. http://www.ncbi.nlm.nih.gov/pubmed/12601224