Health Sciences/Healing Arts: a modest proposal

[Tom Morris]

I think the current layout with Health Sciences and Healing Arts is a mess. It allows the possibility for people to make articles about extremely suspect treatment methodologies and make some pretty wild claims without scientific oversight. It is a large and exploitable hole in the Workgroup system.

Imagine if we had a workgroup called Political Science and another one called Governing Arts. Those in the Political Science workgroup would put up articles about the history of different types of political system, or on something like the judicial process or the history of healthcare provision or schooling in a particular country and the political issues regarding it. All the people who were editors in the Political Science workgroup would be people with Ph.D's in Political Science, Government and other similar disciplines. The Governing Arts editors, on the other hand, did not go through the standard process of getting a political science degree - instead, they went to their own schools, and were awarded their own type of degree in Governing Arts. They all had different approaches though: some would predict election results by rubbing their hands over statues and listening to what their inner feelings tell them. Others would insert small needles into used ballot boxes in order to figure out how the newly-elected politicians would vote on different issues. They set up a whole set of scholarly journals, institutes and conferences. Their approaches often conflicted, but they were united in one thing: ordinary Political Science was reductionist rather than holistic, and too naïve in claiming to be evidence-based. The Political Scientists, they argued, rely on a Cartesian, hypothetico-deductive, ultra-rationalist method which mistakenly claims to be based "in reality" (itself a product of a phallocentric culture, only held up by dogmatic male power elites) that rejects other, more subtle and nuanced "ways of knowing". When other people thought this kind of talk was rather silly, they conjured up elaborate stories about how they were being suppressed and persecuted by an evil conglomerate of Political Science academics as part of some malevolent plot to... well, by that time everyone pretty much stopped listening realising they were a bunch of hucksterish cretins or paranoid delusionals.

Of course, it would be crass and insensitive for me to suggest that there is any analogy at all between my story and the Health Sciences/Healing Arts divison. 

I think that we need to have a policy: if you make a claim about the efficacy of an 'alternative' treatment, it needs to be verified by someone with a real Ph.D in a real, related medical discipline - your own literature and your own parallel academic system is not enough. Creationists have their own Ph.D programmes, and journals and all that other scholarly apparatus - but I think everyone would have a problem with someone like a Kent Hovind getting into the editorial process in the Biology Workgroup. Health Science/Healing Arts has an even bigger problem than that: it deals with topics that are directly applicable to people's health and well-being. If a person suffering from cancer came along to Citizendium and were to find an article from the Healing Arts workgroup talking about how coffee enemas or vitamin supplements is believed to cure cancer and subsequently uses that rather than, oh, something that actually works, then we are morally culpable for causing someone harm through directing them away from medical treatment that works and on to unproven phooey (even if we disavow legal responsibility).

I have horrible nightmares that someone like Gillian McKeith could apply and become a Healing Arts editor (even with her mail order Ph.D and 46-page pamphlet dissertation from Clayton College of Natural Health), and then where would we be? We'd have articles explaining that you should eat lots of green fruit and veg because they have chlorophyll in them, which will oxidate one's blood (you know, because they are photosynthesisin' while going through one's guts).

The Healing Arts workgroup must not become a way to avoid the rigor of scientific review. On these topics, the credibility of the Citizendium is lost and won. We need a significant review of the role of the Healing Arts workgroup, to see if it's necessary and what steps we can put in place to ensure it does not become a channel through which hucksters can take over the editorial process.

[Hayford Peirce]

Hear! Hear!

[Howard C. Berkowitz]

Well said. I would observe, however, that very good conventionally trained physicians look at both science and art, when, by art, they mean judgment and empathy. I find it ludicrous that some alternative practitioners insist that physicians see a disease and not a person, yet know how often a good medical professor sternly admonishes a resident "treat the patient, not the chart, Doctor. The chart isn't sick."  As an aside, while I know some excellent people that have no interests outside a passion for their profession, some of the best clinicians I know actively have "traditional" artistic interests. Some are active musicians while others just appreciate it -- although I had to be stern with one invasive cardiologist who loves country and western, and inform him that "Achy Breaky Heart" is not good background music for a cardiac catheterization.

One irony is that I know several physicians, as rigorous in science as one can find, who have continuing and positive relationships with what properly are called complementary therapies -- I dislike the "alternative therapy" term as it suggests opposition. Some years ago, at a multidisciplinary symposium on back pain, one chiropractor gave as good a presentation on pain transmission as I have ever heard, and speculated -- and called it such and invited cooperative research -- about how certain manipulations might work, not because of the anatomic model, but because they might be causing the release of pain modulators and suppressing transmitters; it was quite reasonably related to the Melzack & Wall (talk about being robbed of a Nobel Prize) gate control theory.  In chronic pain management, it may be worth a trial of acupuncture, as well as electrical stimulation (or a combination), massage, etc. -- but too many physicians are not aware of the neuropharmacology of chronic pain, that long-term opioids may be appropriate, but that there are also, especially in neurogenic pain, quite a number of mainstream drugs that may be effective. Pain management is one of the areas of medicine where there are both science and art.

Some alternative treatment people are quite sincere, but, aside from any suspicion of "the medical establishment", simply do not share a common language, even when their methods are worth investigating. I have close personal friends who are very sincere about their herbalism, and, indeed, some herbals are demonstrable in randomized controlled trials -- but, unfortunately, they don't have the statistical background to understand a trial, and the inherent uncertainty and controlled risk -- which is why, in the U.S., there is "Phase IV" postmarketing surveillance to look for problems that don't show up in trials, and not because of conspiracy.

For me, it is a red flag when a "healing arts" practitioner refuses to discuss a topic except in their terminology; they are happy to explain how they understand what conventional physicians do, but insist one cannot comment on their approach until one has experienced it. Has anyone followed that logic and said there should be no male obstetricians? For me, one red flag is when someone speaks of "curing" a disease with a known genetic cause. Another red flag is when they mention using "medical laboratory tests", but not only can't describe the decisions they make as a result of the test results, but show no evidence they even know what results the tests produce. "Strengthening the immune system" is one warning phrase, especially if some indirect questioning indicates they have no notion of autoimmune disease.

In other words, I don't think it's unreasonable for CZ to ask the fairly standard list of questions that quite a few consumer health people give as guidance in "how to spot a quack."  Sometimes, one of the fastest ways for a conventional or complementary practitioner can gain credibility is to say what they don't know or can't do -- I remember a thoracic surgeon who said he could make a house call, but there wasn't much he could do there except shake hands. The ones that scare me are the ones that make sweeping statements of all they can cure.

The best possible outcome is that some forum at CZ, be it Healing Arts or something totally different, can be a place where there is less confrontation and more synergy. Even in the mainstream, there can be very useful cross-fertilization among specialists that go across disciplines; I've seen neurosurgeons and neurologists who were contemptuous of one another, but others that properly formed a team. Two people I know are certified both in chiropractic and physical therapy, which they consider complementary -- one said that chiropractic taught him about flexibility and range of motion, while physical therapy gave him a different perspective on building strength.

Unfortunately, however, we seem to be having a degree of sound and fury, perhaps exacerbated by well-meaning people that see argument, but aren't familiar with the specifics of either side.

[Paul Wormer]

There is something very similar, but on a  less important topic, going on with "Cold Fusion".  Personally, I will not argue  against the article,  because  doubtlessly some cold fusionist  blogger will be critical of my arguments. Consecutively,  the E-i-C  may agree that, indeed, I used too many words. However, for the sake of CZ's believability, I hope that some Citizen will be brave enough to challenge the cold fusion article.

[Larry Sanger]

I'm not going to comment on the proposal now (no time to do it justice and then to be able to answer the replies), but I do want to add my usual obligatory pedantic riff...   

The nature of our Neutrality Policy is such that, if you (and mainstream scholarship or science) disagree with an article, you are absolutely licensed to qualify the article in such a way that it does not make positive claims that you disagree with.

Hand-wringing to the effect "Somebody has made an article that advocates a nut theory that no real Wonkologist takes seriously" elicits "So what?" from me.  We want good articles about astrology, tea leaf reading, Scientology, spiritual healing, and various other sorts of (to me) dodgy stuff.  The mere fact that somebody writes an article about a subject, or raises an issue that most people disagree with, means absolutely nothing to me.  And, in saying this, I believe I am saying something that everybody here, at least, can agree with--because in order to join CZ, you had to agree to support our Statement of Fundamental Policies, which includes the Neutrality Policy.

Now, I am very well aware that the advocates of various minority (amateur, nutcase, cult, irrationalist, etc.) views are frequently biased, themselves, in that it seems they would like to use CZ as a platform for advocacy, or to get their views to be presented as on a par with the mainstream views.  If what you're complaining about is the fact that "nutty" views are being presented uncritically, without even the reception of those views by mainstream science being given many lines, then I'll support you 100%.  But if what you're complaining about is the fact that the views are being presented at all, then I can't support you.

FWIW, I personally am an Enlightenment rationalist sort, who does not believe in God, or spiritual stuff really at all.  But I will strongly defend the right of the irrationalists to spew their nonsense--as part of a neutral presentation of competing views!

I know this is all very general and abstract...do with it what you will!

[Howard C. Berkowitz]

I'm not going to comment on the proposal now (no time to do it justice and then to be able to answer the replies), but I do want to add my usual obligatory pedantic riff...   

The nature of our Neutrality Policy is such that, if you (and mainstream scholarship or science) disagree with an article, you are absolutely licensed to qualify the article in such a way that it does not make positive claims that you disagree with.

Let me take that as from the source...what, it is the source?...and ask a procedural question.

Let us say a Wonkologist writes an article in fulsome praise of Wonkology. A non-wonkologist politely points out apparent omissions or contradictions on the talk page. The Wonkologist responds, just inside the edge of actionable discourtesy, that the critic is not qualified to say anything because she is not Wonkologically trained.

The critic responds with a focused criticism from a generally accepted discipline Acornology (we have a missing squirrel about whom we are quite worried0, which is dismissed as out to get Wonkology. The Wonkologist refuses to respond to the specific concern, perhaps where the Wonkologist has said he used a Acorological procedure, and described it in terms that suggest the Wonkologist  completely misunderstands Acornology.

Where are we at that point? Does the neutrality policy mean that we have to start beating the bushes for well-spoken, collaborative Wonkologists, or does someone observe that given the volunteers, it may not be practical to get a calm description, in terms distinguishable from faith or magic, of encyclopedic quality?

Hand-wringing to the effect "Somebody has made an article that advocates a nut theory that no real Wonkologist takes seriously" elicits "So what?" from me.  We want good articles about astrology, tea leaf reading, Scientology, spiritual healing, and various other sorts of (to me) dodgy stuff. 

Are you not making an assumption that there exist Wonkologists that will participate in the best of the CZ dream, while we are having trouble getting a critical mass of authors and contributors in a "mainstream" discipline?

The mere fact that somebody writes an article about a subject, or raises an issue that most people disagree with, means absolutely nothing to me.  And, in saying this, I believe I am saying something that everybody here, at least, can agree with--because in order to join CZ, you had to agree to support our Statement of Fundamental Policies, which includes the Neutrality Policy.

FWIW, I personally am an Enlightenment rationalist sort, who does not believe in God, or spiritual stuff really at all.  But I will strongly defend the right of the irrationalists to spew their nonsense--as part of a neutral presentation of competing views!

I know this is all very general and abstract...do with it what you will!

Now I'm confused. If I were to write an article about the Internet that describes it as run by elves under the direction of the Illuminati...or was it the Trilateralists?...an Editor,qualified in the subject, can eventually rule it out, much in the way Churchill described the proposition that one must not end a sentence with a preposition as "arrant nonsense up with which I shall not put"?  That certainly seems to be a reasonably accepted Editor role.

I don't understand, then, how there can be a neutral presentation of Wonkology, when all Wonkologists say that their field must be as accepted on faith and spew clouds of smoke when questioned on anything.

[Hayford Peirce]

There is something very similar, but on a  less important topic, going on with "Cold Fusion".  Personally, I will not argue  against the article,  because  doubtlessly some cold fusionist  blogger will be critical of my arguments. Consecutively,  the E-i-C  may agree that, indeed, I used too many words. However, for the sake of CZ's believability, I hope that some Citizen will be brave enough to challenge the cold fusion article.

Well, Chris Day and I have begun, but are encountering some resistance.  I wish some other people would jump in!

[Howard C. Berkowitz]

I'm not going to comment on the proposal now (no time to do it justice and then to be able to answer the replies), but I do want to add my usual obligatory pedantic riff...   

The nature of our Neutrality Policy is such that, if you (and mainstream scholarship or science) disagree with an article, you are absolutely licensed to qualify the article in such a way that it does not make positive claims that you disagree with.

I hate to put a second comment where I have already commented, but recent events suggest to me that this is the correct context.

First, I think it wise that I do not make further comments, or read, the homeopathy discussion/article.

The crux of the problem is that the most provocative irrationality is on the talk page. Unfortunately, if the irrationality isn't countered there, sometimes on fairly technical medical or statistical grounds, it has gotten into the article, and there are new battles that go back to the talk page. IMHO, it's a lose-lose proposition; this is a case of "know when to hold and know when to fold." I fold. While I find my command of English adequate for most purposes, occasionally, other languages have a certain elegance, especially "Yinglish" - Americanized Yiddish. I find the homeopathy article to have gone beyond irrationality into mishegoss.

Second, I believe the health sciences/healing arts distinction is fundamentally broken.  If others feel this way, is that appropriate for a proposal to the Editorial Council?

Third, Larry, I have some sympathy with having a place to have irrationalists spew their nonsense, but there are rational limits. I will very briefly cite a real-world example of believing that there are proper places for spew. It is not, I believe, a violation of Godwin's Law if I speak of a personal, face-to-face encounter with uniformed, swastika-armbanded members (around 1971) of the American Nazi Party. While the outcome of the incident was more Monty Python than anything else, I want irrationalists to spew in a place where the irrationality can be demonstrated.

I do not, however, see how some of the healing arts irrationality can be presented neutrally, at least in the discussion at hand. In other words, I fail to see how spew can be presented neutrally enough, with the limited resources available, to be a posiitive contribution to the integrity of Citizendium.

I defer to your authority as to what should be included, and will simply stay out of Healing Arts.  If, at some future time, there is a discussion if there should be a separation -- I note that the National Institutes of Health, as health-sciency a place manages to survive containing the National Center for Complementary and Alternative Medicine (in the same organizational niche as the Center for Scientific Review) -- CZ might manage a similarly Big Tent for health.

[analytikone]

Hi, since the forum rules don't allow me as an anonymous user to write on this board, I would just like to draw attention to the fact that I, sharing the worries expressed here, have already approached this subject at http://forum.citizendium.org/index.php/topic,951.0.html and proposed two possible criteria (which can be combined) for selecting "healing arts" editors in order at least to avoid the worst excesses.

[Howard C. Berkowitz]

Hi, since the forum rules don't allow me as an anonymous user to write on this board, I would just like to draw attention to the fact that I, sharing the worries expressed here, have already approached this subject at http://forum.citizendium.org/index.php/topic,951.0.html and proposed two possible criteria (which can be combined) for selecting "healing arts" editors in order at least to avoid the worst excesses.

First, I do hope you will consider joining non-anonymously. Not everyone has the same reasons to want to be anonymous, but, while it is indeed the exception here, it is possible to get a pseudonym if there is a specific reason to the people that approve accounts. On behalf of one colleague, who sadly was unable to participate due to being relocated to a part of the world with little Internet access, the person had a plausible reason -- working for an organization that absolutely forbade publication other than by designated officials -- and the CZ person indicated that the person's request sounded reasonable.

If I may summarize, you offer two criteria, with the option of either or both being used. One is that the subject is taught in a recognized university as a professional discipline, and the other is that the technique/art has been demonstrated efficacious in a significant clinical trial. The second point is rephrased a bit; you used "better than placebo", but that is not the current ethical criterion if a recognized treatment exists. If the latter is true, than the control arm of the trial is the current "gold standard' of treatment. (which I find amusing, since gold preparations, once important drugs in treating rheumatoid arthritis, are not the gold standard).

Those certainly seem a reasonable starting point. I'm not sure how rigorously to use "university", as there are some quite well recognized health sciences specialties that, if a gradute program, may be accredited but not in a university (podiatry and optometry come to mind).  Even when one comes from an undergraduate program, I certainly wouldn't rule out the expertise of a registered nurse who went through a two-year certificate program, passed the same national boards as the BSN nurses, and has substantial experience.

In the U.S., there is a considerable debate over what a clinical trial should show before a new treatment is accepted. The current standard, for drugs, is that the new drug must first demonstrate safety, and then efficacy at least equal to an accepted drug. Some healthcare economists argue strongly against adding a drug that is no better than what is available. While I will have to go look up the reference, I believe the U.K. approval organization is now requiring that the new drug show improvement.

While I think the demonstration of superiority makes sense in a country with huge drug expenses, with the development of "me too" drugs appearing to drive up cost, that argument may not be fair in this case. Personally, I much prefer the term "complementary and alternative medicine" to healing arts, and I get nervous about those arts that act as partial or complete alternatives to conventional (I have no better term; "allopathic" is more of a derogatory term used by some alternative disciplines).

Again dealing with U.S. case law, parents have been held guilty of manslaughter when they insisted on religious healing only for a child who died from a condition that has a recognized and effective treatment, such as insulin for type 1 diabetes. When religion is involved, huge constitutional and bioethics questions arrive. Could this manslaughter criterion apply here -- if an individual under the care of an alternative practitioner dies, is that treated as it probably would be by conventional medicine: not everyone can be saved? I don't have a simple answer. There are ironies; while anecdote is not the singular of data, I lost an inlaw and close friend to what I considered the malpractice of what I'd call a complementary practitioner. The particular art involved is one I have used myself, with active collaboration between the healer and a board-certified academic internist. In the incident I mentioned, when I spoke to the relative, for the first time in perhaps two weeks, just over the phone I heard him describe symptoms that caused me to tell him to call an ambulance. Sadly, he was already in an emergency room, but the aneurysm of the abdominal aorta, which had apparently been giving warning signs for over a week, had already ruptured; he died a few hours later. At the time, the operative mortality for this condition would have been about fifty percent, which still is better than zero.