What is the medical version of the Courtier’s Reply?

We find a perfect example of this detestable apologetic accommodationist approach for ‘sophisticated’ thinking over at Sabio Lantz’s popular Triangulations, offered up on platter in his post Why do you reject Homeopathy? This is the medical version of the Courtier’s Reply that invokes the need for some level of sophistication to be exercised in order to reject the tenets of homeopathy properly… while making room for what starts out to be hypothetical efficacy derived from it and morphs into actual efficacy associated with it.

Sabio lists three main categories into which a reader’s rejection may fall: tribal doubt (no other ‘tribe member’ accepts it so, being part of this ‘tribe’, you don’t either) , mechanism doubt (the mechanistic explanation is inadequate), and smattering of science (you believe some studies you’ve heard in passing that claim no evidence of efficacy). A fourth classification is for those who have done in-depth research into the applicable science and waded through all the counter evidence of non-efficacy before arriving at an opinion of rejection (similar to the level of knowledge about the finery that is needed before one is allowed to comment of the nakedness of the Emperor).

He is following the tried and true method of the accommodationist so that he can ask with a straight face, Do you agree that something can work in spite of the explanation offered? Notice the words ‘CAN WORK’. That sounds like a reasonable question, doesn’t it? But then, Poof! ; suddenly we’re talking about homeopathy as if it DOES WORK – even if this explanation is absolute bunk – which is slowly revealed to be Sabio’s position all along… beginning with the comment that “I strongly agree that much is to be learned from alternative medicines which has nothing to do with the science behind their treatments.” Really? And what might that be? How gullible people are? How undermining healthy scepticism helps woo-peddlers? How faith-based belief can be accommodated with conflicting knowledge? Do tell, Sabio; do tell. In this post, of course, we never do find out.

What he means by has nothing to do with the science behind their treatments , of course, is the LACK of good science, plausible science, that informs these alternative, complimentary, integrated, holistic, natural treatments… treatments  that are somehow qualitatively different from what we call efficacious medicine but still cause effect, but once you start down the path to presenting the Emperor as if he could be clothed – that woo treatments CAN WORK even if the explanation is wrong  – it is difficult to regain one’s intellectual footing. But intellectual integrity is never the goal of accommodationism; it’s all about appearing to be non judgmental about woo and hyper-critical of justifiable scepticism. The real goal at the end of the day for the accommodationist is to present himself as both a supporter and defender as well as a reasonable sceptic of woo (unlike those ranters and hyper-rational people who dismiss woo claims out of hand because they have no good reasons to believe them in the first place).  It’s tricky ground for accommodationists when the two – woo and scepticism – are in conflict from the get go (see here for why the treatment should banned according the British Medical Association).

Well, what is the explanation of homeopathy that is being dismissed by some level of ‘sophisticated rejection’?

Orac explains:

Most skeptics are aware of the two main principles of homeopathy, neither of which is based on anything resembling good science. The first principle is known as the Law of Similars, which is commonly phrased as “like cures like.” The concept is that the way to choose a homeopathic remedy is to choose something that causes the symptoms the practitioner wants to alleviate. Of course, there’s no general scientific or biological principle to support the Law of Similars. In reality, it’s nothing more than a variant of ancient concepts of sympathetic magic. Yet it is the main basis of all of homeopathy.

The second big law of homeopathy is known as the Law of Infinitesimals. This is the most famous principle of homeopathy that states that the way to make a remedy stronger is to dilute it, a principle that laughs at chemistry, physics, and biology. Indeed, common dilutions of homeopathic remedies (for example, 30C, which is 30 serial 100-fold dilutions, or a dilution of 10⁶⁰) have been diluted so much that the odds that even a single molecule remains in the remedy are, well, infinitesimal. That’s why it’s not for nothing that skeptics frequently point out that homeopathy is nothing but water. It’s even loonier than that, though. The reason is that dilution is not enough. At each step, we are told by homeopaths in all seriousness that the succussion at each dilution step is critical to “potentize” the remedy. Samuel Hahnemann himself, the inventor of homeopathy, used to succuss his remedies by slapping them against a Bible. These days, in at least one case, a big company like Boiron have machines that do the succussion automatically for remedies like oscillococcinum up to 200C, which represents a 10⁴⁰⁰-fold dilution. Given that there are only around 10⁸⁰ atoms in the known universe, readers can easily see the ridiculousness.

So here’s the thing: what is it that is actually being rejected? I think it’s the central tenet of any woo claim about efficacy  – a faith-based belief that supernatural forces can cause through natural treatment natural effect. Sabio suggests that there really, really, really is evidence of efficacy in some of these woo treatments (“I have demonstrated acupuncture to many folks (not just patients). What is real fun is to get a hyper-rational person to experience things they don’t believe exist”) and that this evidence is available (“But I wager you have not read the studies published by homeopaths showing effectiveness. I worked with an MD homeopath who published in Pediatrics about her research in Guatemala with homeopathic remedies used to treat diarrhea and showed an effect”). See? Homeopathy, says Sabio,  DOES produce evidence of efficacy, and there it is: the switch in language from the reasonable CAN WORK to DOES. But he doesn’t really mean supernaturalism at work, does he?

Let’s look.

Sabio actually means efficacy of placebo when he talk about efficacy: “It is funny how people can allow various placebos (to) work for them and yet now (sic) allow others.” Now think about that comment for a moment because it reveals the sneaky way accommodationists forgive promoters of woo for their lack of specificity… through the subtlety of language.

Sabio is suggesting that placebo is more than what it actually is:  self-reporting of feeling better. He present it as a thing, something you can allow or reject, something that works for you. But that’s not what placebo is, not what placebo means. What placebo means is that mood and belief can have a significant effect on the subjective perception of a treatment’s efficacy. Placebo is not any kind of additional ‘thing’ brought to bear by health care practitioners. Placebo comes only from the patient and its ‘efficacy’ is not directly physiological (although to be clear there are biological mechanisms by which mental processes can affect pain). That’s why placebo is often – and confusingly – referred to as an ‘effect’. But to be equally clear, the more concrete and physiological the outcome, the smaller the placebo effect. At its explanatory extreme, that’s why amputees don’t grow back new limbs no matter how much they may wish it to be.

Notice how Sabio slips in the notion that placebo works ‘for’ someone…as if to say if we build it they will come, that putting efficacy of placebo into the patient’s domain means the same thing as putting efficacy of woo treatments under the control of the patient.  This subtle change in language is insidious because it alters what placebo is – self reporting perception – into something it is not – an efficacious deliverable element of treatment with the patient’s permission. This confusion is rampant in the public domain and, in a nutshell, is the main driver of woo in health care: confusion about causal effect.

From wi-fi fears to chlorination of water, from acupuncture to reiki, from faith healing to anti-vaxers, the confusion about the need to link causal effect is neither clarified nor confirmed by accommodationists who pretend we can put aside causation to better respect faith-based beliefs while maintaining intellectual integrity. We can’t. It’s sneaky, dishonest, and cowardly, and comes at a high cost to respecting knowledge . And here’s why:

I think the notion of what’s true in fact (information that is reliable, consistent, and practical in reality) is knowable and dependable. This is what science is built on and we use practical applications based on exactly this everyday in every way of our lives. Accommodationists and apologists for woo take all this and assume it’s equivalent to some democratic vote. (Sabio: I hope to help interested readers to understand why people practice homeopathy and why millions of patients swear to its effectiveness.  So I am talking to those who are willing to consider not dismissing homeopathy out-of-hand, and instead make an effort to understand why others value it so strongly.) That’s not how reality works. You can’t vote against gravity and expect efficacy because millions want to lift its effects to make room for their anti-gravity beliefs any more than you can vote against evolution to make room for the oogity boogity of creationism or vote against science-based efficacious medicine to make room for homeopathy and expect me to sit by and nod and say how wise that is. It’s not. It’s a denial of what’s true in reality (see above description of what that means)… not a philosophical difference, nor a lack of rejection sophistication, nor any other mitigating term accommodationists would prefer to call it. Belief in woo is a denial of what’s true in reality (remember, see above description of what that means).

And it is downright dishonest to pretend that what’s true in reality (see above description of what that means) is only empirically available in some lab. It’s right in front of our faces all the time and we rely on accurate knowledge about it to function. We really must stop pretending that people who sow doubt about trusting in this knowledge (immediately testable and verifiable) rely on the same kind of faith woo believers exercise to maintain their ‘spiritual explanations’ about the supernatural. It’s not just different; it an exercise of hypocrisy that trusts this knowledge on behalf of their lives on a day to day, moment to moment, basis but then a rationalization using such fallacious arguments like the Courtier’s Reply and sneaky word substitutions to suspends this same knowledge to make room for some woo-soaked apologetic belief in oogity boogity.