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Medical Nihilism
Medical Nihilism
Jacob Stegenga
1
3
Great Clarendon Street, Oxford, OX2 6DP,
United Kingdom
Oxford University Press is a department of the University of Oxford.
It furthers the University’s objective of excellence in research, scholarship,
and education by publishing worldwide. Oxford is a registered trade mark of
Oxford University Press in the UK and in certain other countries
© Jacob Stegenga 2018
The moral rights of the author have been asserted
First Edition published in 2018
Impression: 1
All rights reserved. No part of this publication may be reproduced, stored in
a retrieval system, or transmitted, in any form or by any means, without the
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above should be sent to the Rights Department, Oxford University Press, at the
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You must not circulate this work in any other form
and you must impose this same condition on any acquirer
Published in the United States of America by Oxford University Press
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contained in any third party website referenced in this work.
For those who suffer
Contents
Acknowledgments xi
Parlance xiii
1. Introduction 1
1.1 Medical Nihilism 1
1.2 Our Present Confidence 8
1.3 Brief History of Medical Nihilism 9
1.4 Evidence-Based Medicine 13
1.5 The Key Arguments 14
1.6 The Master Argument 18
1.7 After Nihilism 19
Part I. Concepts
2. Effectiveness of Medical Interventions 23
2.1 Effectiveness and Disease 23
2.2 Naturalism 25
2.3 Normativism 29
2.4 Hybridism 34
2.5 Eliminativism 37
2.6 Conclusion 39
3. Effectiveness and Medicalization 40
3.1 Introduction 40
3.2 Levels of Effectiveness 41
3.3 Scope Requirements for Effectiveness 44
3.4 An Ill for Every Pill 46
3.5 Overdiagnosis and Overtreatment 49
3.6 Targeting the Normative 51
3.7 Objections 52
4. Magic Bullets 54
4.1 Introduction 54
4.2 Magic Bullets 55
4.3 Medicine without Magic 61
4.4 Non-Specificity 63
4.5 Complexity 65
4.6 Conclusion 67
viii Contents
Nancy Cartwright has had the most pronounced influence on this book—the rigor of
her own work has been a constant spur, and her pastoral care has fostered this book in
countless inarticulable ways. Denis Walsh helped to provide the time and the confi-
dence to begin writing. I am grateful to Alex Broadbent, Jonathan Fuller, Maël
Lemoine, and Anna Vaughn for their close reading, questions, and criticisms of draft
versions of large parts of this manuscript at various stages of development.
Many people have offered valuable commentary and discussion on particular
chapters. For this I am grateful to Anna Alexandrova, Hanne Andersen, Richard
Ashcroft, Peggy Battin, Ken Bond, Frédéric Bouchard, Craig Callender, Martin
Carrier, Nancy Cartwright, Hasok Chang, Rachel Cooper, Heather Douglas, Marc
Ereshefsky, Martyn Evans, Luis Flores, Leslie Francis, Fermin Fulda, James Gardner,
Beatrice Golomb, Sara Green, Marta Halina, Jon Hodge, Bennett Holman, Jeremy
Howick, Philippe Huneman, Phyllis Illari, Stephen John, Saana Jukola, Aaron Kenna,
Brent Kious, James Krueger, Adam La Caze, Eric Martin, Leah McClimans, Boaz
Miller, Elijah Millgram, David Moher, Peter Momtchiloff, Robert Northcott, Rune
Nyrup, Barbara Osimani, Wendy Parker, Anya Plutynski, Dasha Pruss, Gregory
Radick, Isaac Record, Federica Russo, Simon Schaffer, Samuel Schindler, Jonah
Schupbach, Miriam Solomon, Jan Sprenger, Georg Starke, Veronica Strang, James
Tabery, Eran Tal, Mariam Thalos, Aleksandra Traykova, Jonathan Tsou, Denis Walsh,
Sarah Wieten, Torsten Wilholt, John Worrall, and Alison Wylie. I am also grateful to
audiences at numerous universities and conferences. A risk of having so many inter-
locutors over so many years is that I am liable to forget to thank all of them here. I am
truly sorry if I have done so.
Dr. Brent Kious (psychiatry) participated in one of my philosophy of medicine
seminars, and Dr. Benjamin Lewis (psychiatry) allowed me to shadow his clinical
work with patients at the University of Utah Neuropsychiatric Institute. Dr. Beatrice
Golomb (internal medicine) introduced me to some of the problems of assessing
harms of medical interventions. Dr. Dick Zoutman (infectious diseases) first empha-
sized to me the practical difficulty of amalgamating diverse evidence. Dr. Luis Flores
(psychiatry), health policy analyst Ken Bond, and epidemiologist David Moher pro-
vided written commentary on particular chapters. I am grateful to Dr. Samuel Brown
(intensive care), Dr. Howard Mann (radiology), Dr. Jeffrey Botkin (pediatrics and
research ethics), and Dr. Willard Dere (personalized medicine) for valuable discussion
on several general themes from the book.
Parts of this book have appeared in previous publications. A version of Chapter 2
and some of Chapter 3 was published as “Effectiveness of Medical Interventions” in
Studies in History and Philosophy of Biological and Biomedical Sciences (hereafter
xii Acknowledgments
Studies C) (2015a). A version of Chapter 5 was published as “Down with the Hierarchies”
in Topoi (2014). A version of Chapter 6 was published as “Is Meta-Analysis the
Platinum Standard?” in Studies C (2011). A version of Chapter 7 was published as
“Herding QATs: Quality Assessment Tools for Evidence in Medicine” in Classification,
Disease, and Evidence: New Essays in Philosophy of Medicine (2015b). A version of
Chapter 8 was published as “Measuring Effectiveness” in Studies C (2015c). A version
of Chapter 9 was published as “Hollow Hunt for Harms” in Perspectives on Science
(2016). Appendix 4 was developed with Jan Sprenger in “Three Arguments for Absolute
Outcome Measures” in an article in Philosophy of Science (forthcoming). Parts of
Chapters 8 and 12 are published as “Drug Regulation and the Inductive Risk Calculus”
in Exploring Inductive Risk (2017). I have extensively reworked, excised, and added
material from these articles to improve and clarify their arguments and to unify them
as parts of a coherent whole. Most of Chapters 1, 4, 10, 11, 12, and the technical material
in the appendices are new.
I began this book while I was a Fellow of the Banting Postdoctoral Fellowships
Program, administered by the Government of Canada, and held at the Institute for
the History and Philosophy of Science and Technology at the University of Toronto.
I am grateful for this generous support. It is a nice historical accident that my
research for those two years was supported by a program named after Frederick
Banting, the scientist who discovered the biological basis of, and effective treatment
for, type 1 diabetes. Banting’s great achievement, which saved so many lives and
mitigated profound suffering, has raised my standard for what we can hope for from
medicine, and I use this standard in the arguments that follow.
I wrote most of this book while at University of Utah, University of Victoria, and
then University of Cambridge—these institutions provided generous time for me to
devote to writing. I made the final touches during a fellowship at the Institute of
Advanced Study in Durham University. This idyllic setting of riverside paths, medieval
stone roads, and wooded trails was conducive to testing a claim made by Hippocrates,
an early medical nihilist and the symbolic parent of western medicine: walking is our
best medicine.
Parlance
RD risk difference
RR relative risk
RRR relative risk reduction
SEU simple extrapolation, unless
SSRI selective serotonin reuptake inhibitor
1
Introduction
Part III summarize the arguments for medical nihilism and what this entails for med-
ical research and practice.
This book applies philosophical tools to scientific research to defend a radical pos-
ition about medicine. But this book is a work in philosophy of science in a second (and
secondary) sense, by applying scientific tools and findings to philosophical topics. In
Chapter 2, for example, I defend a hybrid theory of health and disease. In Chapter 7
I criticize the view known as epistemic uniqueness, which holds that evidence uniquely
justifies a particular belief. There is an emerging view in philosophy of science that in
many aspects of science, facts and values are inextricably intertwined. The arguments
in this book support this: in Part I the theory of disease that I elaborate requires both
an empirical and a normative component, in Part II I show that social values can per-
meate inductive reasoning, and in Part III I note the role of values in reconsidering
research, practice, and regulation in light of medical nihilism. Throughout the book I
illustrate the insights that can be gained by modeling scientific inference with formal
philosophical tools.
More generally, this book is an exercise in contextualized demarcation. Philosophers
of science have long attempted to demarcate good science from bad science, or pseudo-
science. A lofty ambition of philosophers has been to articulate a principle that can
demarcate good science from bad in a general and context-free manner. The trouble
with this ambition is that every such principle has faced counterexamples. Popper’s
principle of falsificationism is perhaps the most famous of these approaches. Good
science, according to Popper, involves the development of theories that make precise
predictions, and good scientific activity involves rigorous attempts to refute such pre-
dictions and thus the corresponding theories (Popper, 1959 [1935]). Kuhn’s notion of
paradigms was also influential: normal science is based on a paradigm, and empirical
fact-gathering in the absence of a paradigm is not science, according to Kuhn (1962).
Recently, Hoyningen-Huene (2013) argues that a distinctive feature of science is its
systematicity, though critics have noted that systematicity is neither necessary nor
sufficient for an endeavor to be scientific. Based on what appears to be an intellectual
standstill, many philosophers have given up on the attempt to develop general, con-
text-free principles of demarcation. But from this standstill it does not follow that one
cannot identify unreliable science in a particular domain or context. Such contextual-
ized demarcation is a central ambition of this book.
This book, then, contributes to contemporary debates in philosophy of science by
focusing on technical details within science. However, the primary aim of this book is
to defend a radical position about medicine by using the tools of philosophy of science.
To use Godfrey-Smith’s term, this book is a work in ‘philosophy of nature’—assessing
science, not in its raw form but rather through the lens of philosophy, to determine the
most compelling view about what its message is (2009). Similarly, to use Chang’s term,
this book is a work in ‘complementary science’—the critical reconsideration of ideas
taken for granted in science, with the aim of enhancing our understanding of nature,
and perhaps improving our lives (2004). This is a work of philosophy of nature or
4 Introduction
complementary science, in which the subject is one of our most important institutions,
one of our best-funded sciences, and a practice upon which the most fragile and
vulnerable members of our society depend.
To evaluate medical nihilism with care, toward the end of the book I state the
argument in formal terms. A compelling case can be made that, on average, we ought
to assign a low prior probability to a hypothesis that a medical intervention will be
effective; that when presented with evidence for the hypothesis we ought to have a low
estimation of the likelihood of that evidence; and similarly, that we ought to have a
high prior probability of that evidence. By applying Bayes’ Theorem, it follows that
even when presented with evidence for a hypothesis regarding the effectiveness of a medical
intervention, we ought to have low confidence in that hypothesis. In short, we ought to be
medical nihilists. The master argument is valid, because it simply takes the form of a
deductive theorem. But is it sound? The bulk of this book argues for the premises
by drawing on a wide range of conceptual, methodological, empirical, and social
considerations.
My use of the Bayesian apparatus is meant to provide clarity to the master argument
of the book and unity to its chapter-level arguments. This tool is often employed by
philosophers, but since some of my audience may not be familiar with it, I provide a
simple overview of it in Appendix 1. This overview will also be helpful to students who
have not yet been exposed to this elegant tool. However, this book is far from being a
work in formal philosophy. I use the formalizations only as needed, and I place most of
the formal work in appendices. Moreover, for the most part I avoid taking a stand on
the debate about the fundamental nature of probability and the foundation of statis-
tics, except insofar as the master argument assumes that the prior probability of a
hypothesis ought to be taken into account, to the extent that it can, when assessing its
posterior plausibility (even some card-carrying frequentists grant this). The argu-
ments I raise for medical nihilism are compelling regardless of one’s allegiance to a
particular school of statistics or theory of scientific inference. Bayesianism is beset
with well-known problems—I use it here only to unify and clarify an otherwise dispar-
ate and complex argument. This book has more in common with feminist philosophy
of science, in that it is a critical examination of the methods and results of scientific
practice, with attention to the social nexus in which such activity occurs.1
My position should not be interpreted as antithetical to evidence-based medicine,
or as supportive of other critical views of medicine. On the contrary. The medical
interventions that we should trust are those, and only those, that are warranted by
rigorous science. The difficulty is determining exactly what this appeal to rigorous
science amounts to, which is why medical nihilism is a subject for philosophy of
science. Views similar to medical nihilism are shared by a cluster of critical perspec-
tives on medicine, such as those of the antipsychiatry movement, religious opposition
to particular medical practices, and the holistic and alternative medicine movements.
1
Such as (Longino, 1990), (Solomon, 2001), and (Douglas, 2009).
introduction 5
I do not align myself with these views. Taking a critical position toward medicine
does not imply an alignment with other positions critical of medicine. Indeed, most
of my arguments apply to many of these movements more strongly than they do to
medicine itself.
Moreover, some of the critical arguments I raise here have been made by reflective
epidemiologists and physicians. The work written by physicians, epidemiologists, and
science journalists supporting medical nihilism is vast.2 These thinkers are not cranky
outsiders, but rather are among the most prominent and respected physicians and epi-
demiologists in the world. For instance, the former editor of one of the top medical
journals has claimed that “only a handful of truly important drugs have been brought
to market in recent years” while the majority are “drugs of dubious benefit”
(Angell, 2004b). Or consider the position of the epidemiologist John Ioannidis, sug-
gested by the title of his important article: “Why Most Published Research Findings
Are False” (2005b). The current editor of another eminent medical journal recently
had this to say about contemporary medical science: “Afflicted by studies with small
sample sizes, tiny effects, invalid exploratory analyses, and flagrant conflicts of inter-
est, together with an obsession for pursuing fashionable trends of dubious importance,
science has taken a turn towards darkness” (Horton, 2015). Even a leading textbook of
pharmacology discusses “the inadequacies of current medicines” (Dutta, 2009). In this
book I show that these are well-grounded statements of medical nihilism.
I anticipate several objections. Surely my view does not warrant distrust in all of
medicine? There is no place I would rather be after a serious accident than in an inten-
sive care unit. For a headache, aspirin; for many infections, antibiotics; for some dia-
betics, insulin—there are a handful of truly amazing medical interventions, many
discovered between seventy and ninety years ago. However, by most measures of
medical consumption—number of patients, number of dollars, number of prescrip-
tions—the most commonly employed interventions, especially those introduced in
recent decades, provide compelling warrant for medical nihilism. In the final chapters
I articulate medical nihilism in response to the most salient objections.
Perhaps the most vociferous objection will be that medical nihilism is a general and
empirical thesis, but I have merely selected a handful of examples that appear to be
favorable to the thesis, and even in those cases the empirical evidence does not
straightforwardly support medical nihilism, but does so only from an excessively pes-
simistic perspective. I agree that if I were offering an inductive argument based on the
examples in the chapters that follow, I would be offering a weak argument indeed. To
make such an inductive argument for any particular medical intervention or class of
interventions would require great empirical detail, and perhaps a journalist’s knack
for exposition. But such is not my argument. I have tried to learn from such detailed
2
Recent examples include books by Marcia Angell (2004b), Moynihan and Cassels (2005), Carl Elliott
(2010), Ben Goldacre (2012), and Peter Gøtzsche (2013), and articles by epidemiologists such as John
Ioannidis, Lisa Bero, Peter Jüni, and Jan Vandenbroucke (cited throughout this book).
6 Introduction
arguments offered by others for a wide range of medical interventions, including critical
exposés of antipsychotics, antidepressants, statins, blood pressure lowering drugs, and
drugs for diabetes.3 However, most of my conclusions are based not merely on appeals
to empirical examples, but are based on principled arguments about the malleability of
medical research methods, the thin theoretical basis undergirding many interven-
tions, and the many biases and fraud in medical research. These conclusions apply far
more broadly than the limited examples I employ to illustrate them. Of course, I do not
deny that I have chosen my examples carefully. By focusing on the most widely pre-
scribed classes of interventions, I hope to show that medical nihilism is a compelling
view regarding the most used medical interventions today, which, given their wide-
spread use, is troubling enough.
Nihilism has several connotations. The primary one is existential: the denial that
some particular kind of value, abstract good, or form of meaning in life exists.
Existential nihilism can be a metaphysical thesis, which holds that an alleged entity or
other aspect of the universe does not in fact exist (this is sometimes referred to as ‘anti-
realism’ about the entity in question, and of course there are specific terms for meta-
physical nihilism regarding particular entities, such as ‘atheism’). Existential nihilism
can be an epistemological thesis, which holds that knowledge of an aspect of the uni-
verse is impossible (this is sometimes referred to as ‘skepticism’). Existential nihilism
can be a justificatory thesis, which holds that widely held beliefs about an aspect of the
universe are not justified based on our available evidence. The other main sort of con-
notation of nihilism is emotional: the feeling of despair that might be associated with
any of the forms of existential denial. My use of the term should elicit various connota-
tions in different parts of the book. There is historical precedence in applying the term
‘nihilism’ to medicine. The term ‘nihilism’ was first introduced to philosophy in the
nineteenth century, and within a few decades the term ‘therapeutic nihilism’ was used
to describe the views of prominent physicians such as Holmes, who held that the drugs
of his day should be “sunk to the bottom of the sea” (1860). I discuss this historical
precedence in §1.3.
Nihilism became a prominent view more generally in nineteenth-century western
thought. A primary philosophical project of Friedrich Nietzsche, at the end of the
nineteenth century, was to diagnose and ultimately cure such nihilism (Reginster,
2006). As above, nihilism is the view that particular important ideas or objects or
values lack objective standing or cannot be realized. This is, fundamentally, the thesis
argued for here with respect to medical interventions. Arguably, the highest value of
medicine is the elimination of symptoms of disease and ideally the elimination of dis-
ease itself and thereby the achievement of health. Medical nihilism holds that this
value very often cannot be realized and confidence in medical interventions typically
lacks objective standing. Nietzsche’s proposed strategy for overcoming nihilism was to
3
See (Moncrieff, 2013), (Kirsch, 2011), (Moynihan & Cassels, 2005), and (Gøtzsche, 2013).
Another random document with
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supervision of the Secretary of State of the United States,
and was to continue in existence for a period of ten years,
and, if found profitable to the nations participating in its
advantages, it was to be maintained for successive periods of
ten years indefinitely. At the first session of the
Fifty-first Congress of the United States, that body, in an
'Act making appropriations for the support of the Diplomatic
and Consular Service, etc.,' approved July 14, 1890, gave the
President authority to carry into effect the recommendations
of the Conference so far as he should deem them expedient, and
appropriated $36,000 for the organization and establishment of
the Bureau, which amount it had been stipulated by the
delegates in the Conference assembled should not be exceeded,
and should be annually advanced by the United States and
shared by the several Republics in proportion to their
population. … The Conference had defined the purpose of the
Bureau to be the preparation and publication of bulletins
concerning the commerce and resources of the American
Republics, and to furnish information of interest to
manufacturers, merchants, and shippers, which should be at all
times available to persons desirous of obtaining particulars
regarding their customs tariffs and regulations, as well as
commerce and navigation."
{11}
AMERICANISM:
Pope Leo XIII. on opinions so called.
ANARCHIST CRIMES:
Assassination of Canovas del Castillo.
ANGLO-AMERICAN POPULATION.
ANGONI-ZULUS, The.
ANTARCTIC EXPLORATION.
APPORTIONMENT ACT.
ARBITRATION, Industrial:
In New Zealand.
ARBITRATION, Industrial:
In the United States between employees and employers
engaged in inter-state commerce.
ARCHÆOLOGICAL RESEARCH:
The Oriental Field.
Recent achievements and future prospects.
F. LL. Griffith,
Authority and Archaeology Sacred and Profane,
part 2, pages. 218-219
(New York: Charles Scribner's Sons).
S. R. Driver,
Authority and Archaeology Sacred and Profane,
part 1, pages 150-151
(New York: Charles Scribner's Sons).
H. V. Hilprecht, editor,
Recent Research in Bible Lands,
page 47.
{13}
{14}
A. H. Sayce,
Recent Discoveries in Babylonia
(Contemporary Review, January, 1897).
{15}
The work at Nippur was suspended for the season about the
middle of May, 1900, and Professor Hilprecht, after his return
to Philadelphia, wrote of the general fruits of the campaign,
in the "Sunday School Times" of December 1: "As the task of
the fourth and most recent expedition, just completed, I had
mapped out, long before its organization, the following work.
It was to determine the probable extent of the earliest
pre-Sargonic settlement at ancient Nippur; to discover the
precise form and character of the famous temple of Bêl at this
earliest period; to define the exact boundaries of the city
proper; if possible, to find one or more of the great city
gates frequently mentioned in the inscriptions; to locate the
great temple library and educational quarters of Nippur; to
study the different modes of burial in use in ancient
Babylonia; and to study all types and forms of pottery, with a
view to finding laws for the classification and determination
of the ages of vases, always excavated in large numbers at
Nuffar. The work set before us has been accomplished. The task
was great,—almost too great for the limited time at our
disposal. … But the number of Arab workmen, busy with pickax,
scraper, and basket in the trenches for ten to fourteen hours
every day, gradually increased to the full force of four
hundred. … In the course of time, when the nearly twenty-five
thousand cuneiform texts which form one of the most
conspicuous prizes of the present expedition have been fully
deciphered and interpreted; when the still hidden larger mass
of tablets from that great educational institution, the temple
library of Calneh-Nippur, discovered at the very spot which I
had marked for its site twelve years ago, has been brought to
light,—a great civilization will loom up from past
millenniums before our astonished eyes. For four thousand
years the documents which contain this precious information
have disappeared from sight, forgotten in the destroyed rooms
of ancient Nippur. Abraham was about leaving his ancestral
home at Ur when the great building in which so much learning
had been stored up by previous generations collapsed under the
ruthless acts of the Elamite hordes. But the light which
begins to flash forth from the new trenches in this lonely
mound in the desert of Iraq will soon illuminate the world
again. And it will be no small satisfaction to know that it
was rekindled by the hands of American explorers."
{17}
"Among the more important finds so far made, but not yet
published, maybe mentioned over a thousand cuneiform tablets
of the earlier period, a beautifully preserved obelisk more
than five feet high, and covered with twelve hundred lines of
Old Babylonian cuneiform writing. It was inscribed and set up
by King Manishtusu, who left inscribed vases in Nippur and
other Babylonian cities. A stele of somewhat smaller size,
representing a battle in the mountains, testifies to the high
development of art at that remote period. On the one end it
bears a mutilated inscription of Narâm-Sin, son of Sargon the
Great (3800 B. C.); on the other, the name of Shimti-Shilkhak,
a well-known Elamitic king, and grandfather of the biblical
Ariokh (Genesis 14). These two monuments were either left in
Susa by the two Babylonian kings whose names they bear, after
successful operations against Elam, or they were carried off
as booty at the time of the great Elamitic invasion, which
proved so disastrous to the treasure-houses and archives of
Babylonian cities and temples [see above: BABYLONIA]. The
latter is more probable to the present writer, who in 1896
('Old Babylonian Inscriptions,' Part II, page 33) pointed out,
in connection with his discussion of the reasons of the
lamentable condition of Babylonian temple archives, that on
the whole we shall look in vain for well-preserved large
monuments in most Babylonian ruins, because about 2280 B. C.
'that which in the eyes of the national enemies of Babylonia
appeared most valuable was carried to Susa and other places:
what did not find favor with them was smashed and scattered on
Babylonian temple courts.'"
Prof. H. V. Hilprecht,
Oriental Research
(Sunday School Times, January 28, 1809).
See, in volume 1,
EGYPT.