- Does it work?
- How good is it?
- How good is the evidence?
- Is it cost effective?
- How can I find out more?
How do agencies such as NICE decide what treatment works and what does not? How do they decide if a treatment represents good value? If a friend recommends alternative healthcare, how should we judge it? If something is advertised as “natural” what does this mean and is it really better? We are constantly bombarded with information about scientific and medical matters but most people lack the ability to interpret it.
This chapter has the following headings:
- Seeking the Truth
- What is Evidence?
- Living with Uncertainty
- Sorting the Wheat from the Chaff
- References and Links on this Site
- Further Resources
- Science with Care
- Site Index
If you wish to go directly to that section, click on the blue underlined title above.
There are many questions you may be asking:
- Should I really bother about smoking, obesity and lack of exercise?
- What is a healthy diet?
- Should my child have the MMR vaccine?
- Are “natural” remedies safer and more effective than those that I can get from my doctor?
- Is global warming really as catastrophic as made out?
- Is GM food safe to eat?
- Is organic food a healthier alternative?
We shall examine how these questions have been addressed and how we can examine the evidence. This website covers a wide range of topics and everyday questions that are asked. It will help you to take informed decisions. It will demonstrate many pitfalls. We shall come across “self-evident truths” which are not true, self-appointed experts with no qualifications or knowledge of the subject and frank fake news.
Seeking the Truth
Most medical research is conducted not in laboratories using single cell lines or inbred mice but on that broad spectrum of people we call patients. Just because something seems to work for one person does not mean that it will work for everyone. If someone got better it was not necessarily the medicine or the intervention that caused it. We shall see that we need large and well-conducted clinical trials to get to the heart of what works and what does not. These trial will be described later.
This website aims to encourage the reader to have an enquiring mind and a constant desire to ask questions and not simply to accept dogma. It helps to know the appropriate questions to ask and how to find the answers. In Monty Python’s Life of Brian, Brian asked his mother, “Why are women not allowed to go to the stoning?” to which she replied, “Because it’s written! That’s why!” All too often we accept what we are told as “tablets of stone”.
Not everything that is said, written or even published in scientific journals is true. Even less we should believe what is recycled in newspapers. In this age of “post truth” where emotion takes precedence over evidence and much of what people believe is gleaned from social media which is far less reliable than even the worst newspaper, we must seek the truth and not “alternative truth”. We should ask questions, seek explanations that can be tested for validity and ask if there may still be an alternative explanation.
This is true for all aspects of life. Do longer prison sentences really reduce crime or are they an expensive and useless political sop? Do speed cameras really save lives? In business management ask, “What do we do? Why do we do it? What is the evidence that it is a cost-effective practice that benefits our business?” Often the claim “scientifically proven” means that there is not a scrap of real evidence to support it. Asking questions should be part of everyday life. You will be surprised at how much you accept on flimsy or no evidence.
Even the NHS was established on a tenet that was wishful thinking rather than evidence-based. It is said that at a time of great Government spending and post-war austerity with a massive national debt, Aneurin Bevin convinced the Treasury that a health service, free at the point of access, would so improve the health of the nation that the amount of money spent on health care would actually decline. There was no evidence to support this assertion. By 1964 the Minister of Health, Enoch Powell, said that there is no limit to the amount of money that can be spent on a national health service. We must all agree that NHS funding is a bottomless pit.
Do not believe all you read in the newspapers or see on the television. The media call MRSA the “flesh-eating virus” but MRSA is neither flesh-eating nor a virus. Test tube babies are not produced in test tubes. A scare story will always be reported, no matter how flimsy the evidence whilst good research that reassures is thought to have no news value. This is a major cause of distorted public opinion. There are also a number of publications that would never like to spoil a good story for the sake of the truth.
However, even the most unreliable of newspapers is pristine compared with the Internet. That does not stop people from accepting the most ridiculous of stories. During his four years as president of the USA, Donald Trump brought fake new and telling blatant lies to a new level. Be careful where you get your information. It may be a purveyor of fake news. A UK charity called fullfact.org has published a report on the first six months of its third party fact checking programme for Facebook. People score points and points means advertising revenue, for hits on their websites. This requires sensation, not accuracy. Indeed, the most outrageous will get the most hits.
What is Evidence?
We need evidence, not passion. Evidence is produced by testing theories. Only then is it possible to reach a conclusion and to test the strength and reliability of that conclusion. The 20th century philosopher Karl Popper stated that a theory that cannot be disproved has no scientific validity. It is easy to demonstrate that something is untrue but almost impossible to prove that it is true. Therefore, we test for untruth. Sir Karl Popper explained the problem with the statement “all swans are white”. We may see hundreds or even thousands of swans and all the swans that we see are white. Therefore the statement is probably true but it is not proven. However, as soon as we see a single black swan the statement is disproved. If we have tested a hypothesis rigorously in several ways and failed to demonstrate that it is untrue; we may presume that it is true. An untested theory is useless.
Sir Karl Popper’s approach of attempting to disprove a hypothesis is the fundamental basis of modern science. Before it, the approach tended to be verification and this can lead to spurious results. Seeing a white swan or even a dozen white swans does not confirm the assertion that “all swans are white”. A Marxist may look at any newspaper story and interpret it as confirming his concepts of class war. That does not make him right. A psychoanalyst may tell all his patients that they have had a traumatic event in their early lives and this is the root of their problem, even if they do not remember it. Neither Marxism nor Freudian analysis should be seen as scientific disciplines despite claims to the contrary.
Science relies on evidence. Philosophy is based on logic. Religion provides revelation. According to the American National Academy of Sciences in 1981, “Religion and science are separated and mutually exclusive realms of human thought where presentation in the same context leads to misunderstanding in both.” Science, religion and philosophy will all be discussed at times. Science and religion should not be seen as mutually exclusive or antagonistic. Philosophy is also required as it determines how we think and how we approach problems. In religion we need some evidence that our faith is well placed. Jesus said, “You can tell a tree by the fruit that it bears.” Logic needs to be tested too. There are areas of overlap between these three disciplines and areas where they are on their own.
Scientists and politicians reach conclusions in different ways. A scientist will examine the evidence and assess it for relevance, validity, reliability and strength. Then he will draw a conclusion. A politician starts with a conclusion, usually based on political bias or instinctive response. He then searches for evidence to support his conclusion. This will be enthusiastically accepted, no matter how tenuous or unreliable it may be. He will then reject all evidence to the contrary, no matter how cogent it may be. Great Britain has had only one prime minister with a degree in science but on graduating she took up law to further her political career. Germany’s Angela Merkel has a background in science and she is said to be more analytical than most politicians. This site will concentrate on science rather than politics, history or religion but it will not hesitate to stray from time to time.
Living with Uncertainty
When we look at the tools used in science, including statistics which shows the chance of something happening or being random, and when we look at accuracy and reproducibility, we come to the inescapable conclusion that we can be absolutely certain about nothing. The chapters on Randomised Controlled Trials and Basic Maths in Medical Research and Decision Making will reinforce this. This is nothing new. Philosophers since the pupils of Plato have argued that we can be absolutely sure of nothing. There may be the tiniest chance that something is wrong, but that means that it is possibly not right. In criminal law, the jury has to decide that the accused is guilty “beyond reasonable doubt” and it this is not reached, they must issue of verdict of not guilty.
Humans do not like this. They crave absolute certainty. Is a drug absolutely safe? Is it effective? Is a vaccine safe? We can never be absolutely certain and part of understanding science involves the ability to live with uncertainty. Some people find this difficult.
This is what is so attractive when people offer absolute certainty. They include religious extremists. They include political extremists. Strict discipline means that people are given absolutes and do not have to think for themselves. People can look fondly on dictators who offer them absolutes. Even conspiracy theories offer revelation and the path to enlightenment, although a cursory, critical approach will show the utter fallacy.
Hence, developing a critical approach and accepting that something may be beyond reasonable doubt but nothing is absolutely certain, is not only necessary to understand medical science. It also helps us to cope with the real world and to reject religious or political extremes and it helps us to reject the siren calls of cults, fake news and conspiracy theories. The apostle Thomas, often known as “doubting Thomas” often has his doubting portrayed as a weakness. I disagree. He doubted, he found evidence rather than just taking other people’s words, and then he believed. No one took Thomas for a fool. Learn to embrace uncertainty and enjoy it.
What is Evidence?
We shall examine a number of issues, mostly related to health, and the evidence available. As well as false experts claiming authority there are many who try to denigrate those who do have expertise. The media is full of this. Even if science reporters understand the science they may be overruled by the editor. Shock, Horror, Scandal, Cover-up are the headlines that sell newspapers. A sober and balanced appraisal is far less attractive. It is easy to get people to believe what they want to believe and they will accept it with flimsy or no evidence. On the other hand, even the most cogent argument may be rejected by those who do not wish to believe. Sound bites and emotion can be more powerful than evidence.
We must also be careful to approach any issue with an open mind, being able to accept that at times our preconceptions may be wrong. When researching an issue there is a tendency to reinforce original expectations. This is called “confirmation bias” and it is as common in science as elsewhere. In his farewell address in January 2017 Barrack Obama said, “We become so secure in our bubbles that we start accepting only information, whether it is true or not, that fits our opinions, instead of basing our opinions on the evidence that is out there.” Homophilous sorting is our tendency to congregate with the like-minded and groups tend to reinforce their own prejudices. Another term is “group think”.
Max Planck, who won the Nobel Prize for Physics in 1918 said, “Scientific theories don’t change because old scientists change their minds; they change because old scientists die.” However, it is not only the old who can be stuck in their ways. TH Huxley, one of the great defenders of Charles Darwin from misrepresentation said, “Science commits suicide when it adopts creed.” He also coined the phrase, “The slaying of a beautiful hypothesis by an ugly fact.”
References and Links on this Website
In scientific publications, when the author makes a statement based on evidence from elsewhere, a reference is given for the source of that information. This may be a scientific paper published in a reputable journal and the reference will show the reader where to find this. It may refer to a book, an article in a scientific journal or an Internet resource. How to find this information will be discussed later. Usually scientific papers have an abstract that gives a brief summary. Few readers will wish to read whole papers. They can be long, tedious, turgid and often badly written. However, sometimes access to full text is given for important and useful papers. References will be given here too and for the full text of scientific papers it will state [full text]. Usually, this will be done only if the full text is available free of charge. More often online access to the full paper is available for a fee.
However, I must confess that when I quote newspapers I often cite The Times as it is regarded as the newspaper of record. It comes up free on my computer because I have a subscription but for those without a subscription the articles may not be available without charge. However, you may be able to find the same story free of charge elsewhere. Some references that were available when this was written are no longer available and so have been removed but I apologise for any blind links that remain.
When a reference is given it will be followed by a number in superscript. If it is online, the number in superscript will be followed by a short title or description in blue and underlined. If the reference was for the BMJ website, for example, it would look like this:1BMJ If I have my HTML coding correct then clicking on the blue title should lead to the link in a new window. I have checked them all before publishing but availability can change. Clicking on the superscript number will not cause a link but at the end of each section is a list of references and the number can to followed to get this. This includes all references, whether they have online links or not.
If the reference is not available online, such as a book, it will be followed by the title and details in brackets after. As an example2 (Sex and drugs and sport and cheating by Paul Anthony DB Publishing 2014. Page 22.) More details are usually available in the reference section at the end. In the reference section at the end of each article, only Internet links to references are in blue. All else is in normal print. It should look something like this:
- Nobel Prize. http://www.nobelprize.org/
- Sex and drugs and sport and cheating by Paul Anthony DB Publishing 2014. Page 22.
Again, clicking on the blue should lead to the link. This one is for the Nobel Prize organisation.
Hence, words in blue should go to a link. This may be an Internet link or a different part of the page. As you run the cursor over it, the cursor should change from an arrow to a hand. References in magenta are for books or other links that are not available online. Captions for pictures are in green.
Usually references follow a strict format such as the Vancouver style or Harvard style. The style of references here is rather more relaxed. For those not accustomed to reading scientific literature, references do not all have to be followed up but they serve two purposes. One is to show that the statement was based on evidence. The other is to permit the reader to look further into this matter if desired. Numbers are given in superscript and the reference list is at the end of the section. The scientific papers often have an Internet link to at least an abstract giving a brief summary. Where papers are written by many authors “et al” may be seen after a number of names. This is an abbreviation of the Latin “et alia” and means “and others”. The names of journals are usually abbreviated too. If you put them into a search engine you can find the full title. In the next section on the history of science, references are used freely so that the reader may follow Internet sources to learn rather more about the topic or person being discussed. Assessing the reliability of a website will be discussed later.
I am English and so my spelling is English or British rather than American. Thus, I write “rigour, colour and honour” rather than “rigor, color or honor”. Similarly, “oesophagus and oestrogen” start with an o, although in the American it is missing. Oscar Wilde once said that the British and Americans have everything in common except the language.
As I am British, the health care provider that I most often refer to is the NHS or National Health Service. It offers universal healthcare regardless of means or insurance. It was set up in 1948 and is much loved by the British public. I also often mention NICE. This was the National Institute of Clinical Excellence, now the National Institute of Health and Clinical Excellence although the acronym NICE remains. It guides clinicians in evidence-based practice and best practice. It also makes decisions about new drugs or appliances, advising the government if they represent value or if they are very expensive and offer little benefit for the price. This is always a contentious issue and will be discussed. From time to time, I may also relate to my personal experiences as a doctor, although I am now retired.
I hope that this website will help the reader to understand how decisions in medical science are made and how to ask scientific questions and get answers. In the American Declaration of Independence, Thomas Jefferson wrote, “We hold these truths to be self-evident: that all men are created equal; that they are endowed by their Creator with certain unalienable rights; that among these are life, liberty, and the pursuit of happiness”. This was written for a country that still embraced slavery. As we shall see, there is no such thing as self-evident. All dogma should be put to the test. Be inquisitive. Be sceptical. Demand evidence not anecdotes or dogma. Seek the truth.
“We won’t get fooled again” – The Who
- Science and religion: a new introduction. Alister E. McGrath. John Wiley and sons, 2011.
He has an interesting background with an Oxford 1st in Chemistry and then a DPhil but he then turned to Theology. He is Professor of Science and Religion at Oxford University with a major interest in science and religion.
- The logic of scientific discoveries. Karl Popper. Routledge. First published in German 1934, in English in 1959, latest publication 2002.
When first published in 1959, this book revolutionized contemporary thinking about science and knowledge. It remains the one of the most widely read books about science to come out of the twentieth century.
Science with Care
The picture is called The Doctor. It was pained by Sir Luke Fildes in 1896 and now hangs in the Tate Gallery in London. We see a doctor looking pensively at a severely ill girl who probably has diphtheria and despite his care and attention, she will probably die. Her mother hides her head in her arms, unable to look. In the shadow we see her father, also feeling helpless and perhaps wondering how he will pay the doctor’s bill. Usually, doctors did not even bother to submit a bill to people in poverty but gave their services pro bono.
Since then we have had the eradication of diphtheria with an effective immunisation campaign. The National Health Service means that bills are not a problem for either the family or the doctor. The doctor might not be able to do much but at least he cares.
The motto of the Royal College of General Practitioners is cum scentia caritas which is Latin for science with caring. Without science, treatment is uncertain and probably ineffective. Without care, it is meaningless. Both together is the ideal to be achieved.
Luke was the name of the artist but also the name of the author of one of the gospels and the Acts of the Apostles. He is the patron saint of doctors as he was said to be a physician. The narrative in his books was so good that he is also the patron saint of story-tellers and the patron saint of artists as every picture tells a story.
This series of articles has taken me about two years to complete. However, I still return to update it from time to time as required.
If you would like to go directly to any section, click on the title in blue.