Science ain’t over ’til, um…well, never!

Over at sciencebasedmedicine.com, Mark Crislip has a great post on the history of medical advances. First, go read it. WAIT! Don’t forget to come back and read the rest of my post! OK, you can go now.

Good. Welcome back.

There was some talk a while back about “the end of science“. That was an interesting but ultimately fatally-flawed hypothesis.

Then Ben Stein decided that science isn’t over, it’s just evil. EEEEVILLLL!!!11!!

This is also, needless to say, a flawed hypothesis.

In the article you just read at sciencebasedmedicine.com, Dr. Crislip describes the progress made in preserving human life over the last several centuries. This led one commenter to opine:

What has happened to medical progress? It isn’t simple anymore, and the ever increasing complexity does not seem to have much of a payoff.

And that’s why I question some of the mainstream assumptions that I believe have been blocking progress. CAM is still very young and inexperienced. You can’t expect it to make miraculous discoveries over night, when mainstream medical science is proceeding at a sloth’s pace, if at all.

We need more CAM research funding, not less.

There are several problems with these common misconceptions. Medical progress is doing quite well. We did a great job with the whole public health thing. That was a real revolution in human health. It keeps the majority of us alive long enough to deal with other things, like having families, inventing the internal combustion engine, inventing the replacement for the internal combustion engine. It also allows us to worry about other illnesses, and to make profound medical discoveries. For example, the victory against cholera that Dr. Crislip talked about required no understanding of microbiology. The fight against other diseases requires a somewhat more sophisticated knowledge set.

Using HIV as an example, epidemiologists did a great job figuring out what the mystery disease was and how it was spreading. Fortuitously, microbiology and genetics were making incredible strides at the same time, and were able to characterize the pathogen and understand how it works. Finally, medical science, using evidence-based techniques, found effective treatments.

Science is a technique, not a set of data. Science can’t “know everything” because science and knowledge are non-equivalent. The better question than “is science over” (which it can never be, since it is a tool) is, “do we know all there is to know”. The answer to that has to be “no”. There are always more things to learn—just because one of them isn’t “gravity” or “relativity” doesn’t mean that what is left isn’t “knowledge”.

This is simply another attempt by modern medical Luddites to claim that “other ways of knowing” are somehow more valid than science. Of course, they also tacitly acknowledge that knowledge hasn’t ended. So really, they are simply arguing that science isn’t the best way of gaining knowledge, and that only the knowledge that they have accumulated by other means is legitimate.

Sometimes, medicine is referred to derisively as an “art” rather than science. It is both, but we have to make clear where the line is. The science of medicine is in knowing and choosing evidence-based therapies. The art is in knowing how to talk to patients and to guide them in the direction of health. The end of science is an invalid statement. The limit of knowledge is unlikely to be seen in our lifetimes.

42 thoughts on “Science ain’t over ’til, um…well, never!”

  1. Hypotheses and discoveries can arise in almost any way (if I recall correctly, and my Chem Prof wasn’t just telling tall tales, Benzene’s ring structure was first visualized in a dream).

    Where cranks and denialists go wrong is that they do not understand that after an idea is formed, by whatever means, it has to be tested to see if it holds up to Almighty Reality.

    Enter science. Exit bad ideas

  2. “CAM is still very young…”

    Really? Funny, I thought it had been around for centuries. For example, wasn’t acupuncture practiced by ancient Chinese? And didn’t Hahnemann invent homeopathy nearly 200 years ago?

  3. I had WTF moment yesterday while walking through the grocery store. I spied out of the corner of my eye a box of earache pills. I did a double-take, because I thought those were by perscription only. Upon closer examination, I spied the word “homeopathic” written across the top, and yet it is allowed to be sold alongside real medicine. Outrage!

  4. What has happened to medical progress? It isn’t simple anymore, and the ever increasing complexity does not seem to have much of a payoff.

    Huh? No progress? What about HAART, tyrosine kinase inhibitors, HmgCoA reductase inhibitors, antibody/chemotherapy for lymphoma, heck, the discovery of how to use aspirin properly to prevent heart attacks? Do none of these count? What about vaccinations that can, if the various anti-vaxers and fundies don’t stop it, virtually eliminate chronic hepatitis B (and the accompanying hepatomas) and cervical cancer? Or the fact that survival is better now than it was just 10 years ago for virtually every common hematologic malignancy. (Ok, except CLL, but even there progress is occurring, if on a slower time scale.) No progress. Feh!

  5. And, what about the discovery that everything from toenail fungus to erectile disfunction is related to NO levels?

  6. “CAM is still very young…”

    Really? Funny, I thought it had been around for centuries. For example, wasn’t acupuncture practiced by ancient Chinese? And didn’t Hahnemann invent homeopathy nearly 200 years ago?

    CAM is simultaneously ‘still very young’ AND it must be true because people have been practicing it for thousands of years.

  7. The bottom line with science is that you never have The Truth: all theories are subject to change if and when new evidence becomes available. Which means that, in one sense, it is no competition at all as far as religion is concerned. Who’d put faith in a world view that comes out and says up front that it doesn’t know the truth and never will…On the other hand, the approximations are extremely powerful and improving over time.

  8. The bottom line with science is that you never have The Truth: all theories are subject to change if and when new evidence becomes available. Which means that, in one sense, it is no competition at all as far as religion is concerned. Who’d put faith in a world view that comes out and says up front that it doesn’t know the truth and never will…On the other hand, the approximations are extremely powerful and improving over time.

    The bottom line with science is that you have the closest thing to the truth at any given time. When things are found to be incorrect they are corrected. Religion/faith never cured anyone unless you believe the Biblical stories. If an epidemic broke out, where would you run? To your church or to your doctor? For me doctor it is, unless it is nuclear event, then I would just bend over and kiss my ass goodbye.

  9. The classical definition: Art (n): That which is done according to known principles.

    The revised meaning of Art into something nebulous or mysterious is primarily an outgrowth of 18th and 19th century Romanticism (inspirations of the muse and so forth). Art of medicine, art of politics, or even art of science are all perfectly acceptable archaic uses that persist in the current language but had totally different meanings two centuries ago. The known principles of medicine have just shifted from humours to reality-based biology.

  10. The bottom line with science is that you have the closest thing to the truth at any given time.

    Which can be pretty far away. There’s a lot we just don’t know about. It’s a work in progress and considerable progress is occurring.

    When things are found to be incorrect they are corrected.

    Exactly. Therefore, no given statement is ever “the truth” in any absolute way. Everything is eventually corrected, even that which is, on some level, correct. Newtonian physics is “corrected” by relativity but Newtonian physics is still all you need to get to the moon and back safely. It’s just not the whole vision.

    People with moderate knowledge of science sometimes talk about some theory or observation being a “scientific fact”. There are no “scientific facts”, where a “fact” is an absolute, unchallangable and unalterable reality, and pretending that there are only confuses things. Especially when the “fact” in question proves to be false or incomplete as they probably all will with time.

    Religion/faith never cured anyone unless you believe the Biblical stories.

    Placebo effect (for example, prayer) can be useful. On the other hand, the one well done study I know of which considered the effect of prayer found that people who knew that someone was praying for them did worse after cardiac surgery than those who did not. Possibly because they expected to do better and so slacked off on their rehab. Or maybe, I suppose, because there really is a malevolent god who intentionally hurt those who were prayed. I find that less likely, but can’t absolutely rule it out on that data alone.

  11. If an epidemic broke out, where would you run? To your church or to your doctor?

    I’d run to my lab, of course. Well, if it were an epidemic of some new pathogen. If it were an outbreak of something familiar, I’d probably just call in a prescription or take a vaccine. A hospital would hopefully be excessive. (Yes, I know what you meant and I agree.)

  12. EEEEVILLLL!!!11!!

    DOC-TOR Evil! I didn’t study at Evil Medical School to be called ‘Mister’ by you!

    Or perhaps I should mention this guy. Make sure you read all the way to the bottom of the page.

    Medicine is not an art; it is an applied science.

    In the ideal case, yes…

  13. I believe in the scientific method, as I keep saying over and over and over. I just don’t see any reason science has to be materialist, reductionist and non-holistic.

    The great medical advances were in the past. Now we have the mega-drug companies fooling everyone into thinking we are living longer healthier lives thanks to their recent concoctions.

    It isn’t true. The advances we can be grateful for preceded the current drug craze. The current drugs cannot be compared to penicillin or the polio vaccine, for example.

    Medical research has become at least partly a giant scam. We need alternative theories and we need competition.

  14. Oh I forgot to mention — I think surgical technology has made great life-saving advances. But that’s engineering, not really medical science.

    Technology has made detailed knowledge increasingly possible. Technology has been advancing, not biological understanding.

  15. “Using HIV as an example … Finally, medical science, using evidence-based techniques, found effective treatments.”

    But the effectiveness of those treatments has never been tested with controlled experiments. You won’t even do non-experimental outcomes for treated vs. untreated HIV patients.

    You compare old drugs to newer drugs, and conveniently create an illusion of progress.

  16. I believe in the scientific method

    You believe in the scientific method?

    Logic — ur doin it rong.

    I just don’t see any reason science has to be materialist, reductionist and non-holistic.

    This is not a precondition of the scientific method, it’s an outcome.

    Materialist? Show me a testable, parsimonious hypothesis that says spirits exist and have an influence on health.

    Reductionist, non-holistic? You agree with me that the whole is more than the sum of its parts — it’s the sum of its parts plus the sum of the interactions between these parts plus the sum of the interactions between these interactions plus and so on. Right?

    Then certainly the way to start understanding the whole is to figure out the parts, then the interactions between the parts, then the interactions between the interactions, and so on. Right?

    Because that’s what reductionism is.

    Oh I forgot to mention — I think surgical technology has made great life-saving advances. But that’s engineering, not really medical science.

    Nonsense. Knowing where to cut and how to cut, and why, is science.

    You won’t even do non-experimental outcomes for treated vs. untreated HIV patients.

    I’d like to introduce my number one. His name is… Number… Two.

    I’m trying to say that there are experiments that aren’t done because it would be unethical. You don’t simply watch AIDS patients die. Instead you test if the new treatment works better than the old treatment(s) — and if it does so significantly, you stop the experiment and give the new treatment to all, because not doing so would be… well… evil.

  17. “there are experiments that aren’t done because it would be unethical. You don’t simply watch AIDS patients die. Instead you test if the new treatment works better than the old treatment(s) ”

    Yes I understand that perfectly well. The fact remains that yo have no scientific basis for claiming all these wonderful victories for AIDS drugs.

  18. Pec – Engineering is applied science just as surgery is. I am an engineer btw.

    I find it ironic what CAM advocates like to throw around the word holistic when so many CAM treatments go directly from the petri dish to market without animal or human studies.

    As for no progress against cance – tell that to anyone who has been treated succesfully for Hodgkins. I just listened to the memorial concert for Canadain blues/rock guitarist and jazz trumpet player/guitarist Jeff Healy on CBC radio 1. He had his removed at the age of 8 months due to retinal blastoma and survived to age 41 thanks to scientific medicine. His widow mentioned that thanks to progress made in the treatment of eye cancers, their son who has the same mutation has not had to go through what his father went through.

  19. Dianne: We can YELL and SCREAM if you want.

    Militant Agnostic: I to am an engineer. Engineering is grounded in science. It was what sent a man to the moon. Did you hear that pec. Engineering is applied science.

    The great medical advances were in the past. Now we have the mega-drug companies fooling everyone into thinking we are living longer healthier lives thanks to their recent concoctions.

    Here is where I disagree. About the year 2000, if memory serves, the human genome was unlocked. Again if memory serves Time Magazine had an article that described Medical Doctors as auto mechanics that fixed problems without ever opening the hood of the car. Now that the human genome has been unraveled the great discoveries are yet to come. For either good or bad.

  20. “They haven’t? What are these trials then?”

    They compare the effects of different drugs. They never compare drugs to no drugs. They can’t, because that would mean depriving patients of treatments “known” to be effective.

    The result is that no one knows. And it’s very convenient for the drug companies.

  21. Pec, I would think we had several years to compare to before we even knew what HIV was. How old are you? I can remember when sex wasn’t fatal. (Well, unless you fell off of something or were trying to have sex going down the highway at 60mph). Look back to the statistics of those that died before any real treatment was available. Between 1984 and 1985, the reported number of AIDS cases doubled from less than 8,000 to just under 16,000. Look back at what they went through if you want a comparison.

  22. “Between 1984 and 1985, the reported number of AIDS cases doubled from less than 8,000 to just under 16,000. Look back at what they went through if you want a comparison.”

    Sorry, those were US numbers, not worldwide. I should have specified that.

  23. They compare the effects of different drugs. They never compare drugs to no drugs

    Try the first link. It is one of the first studies of AZT versus placebo. Guess what it showed.

  24. What exactly do you mean by the “first link?” Pasting it would be helpful.

    I only saw one link in these comments to AIDS research and there was no placebo.

  25. Also notable are trials like this one. This trial is a blind, placebo controlled study of bestatin in HIV. It showed that the drug had no advantage over placebo. This drug was abandoned. If there is this huge conspiracy to make drug companies lots of money at the expense of HIV+ people, why did they allow this drug to be abandoned?

  26. Try clicking on the blue highlighted phrase “They haven’t?”

    I did. I didn’t see anything about a placebo group. If you are trying to convince me, why make it such a challenge to find your reference?

  27. pec, I had no trouble finding the link here it is again.

    http://www.ncbi.nlm.nih.gov/pubmed/3299089

    The first sentence is:

    “We conducted a double-blind, placebo-controlled trial of the efficacy of oral azidothymidine (AZT) in 282 patients with the acquired immunodeficiency syndrome (AIDS) manifested by Pneumocystis carinii pneumonia alone, or with advanced AIDS-related complex.”

    If you do a google search on:

    “We conducted a double-blind, placebo-controlled trial of the efficacy of oral azidothymidine”

    It shows the one abstract hit and a blog.

    If you do a google scholar search it shows the abstract with 392 references and the NEJM article with 141.

  28. Sorry, folks, but “evidence” and “studies” won’t convince “pec” of anything. He has a classic denialist approach to medicine. “Drug companies are scamming people”. This colors everything he sees, and hides the actual data from him as effectively as a sheet of steel.

    He’s nigh impenetrable.

  29. Probably one of the first AIDS AZT studies. 27 patients over 6 months. After that they probably gave AZT to everyone, based on that single experiment where most subjects dropped out. You would never accept a CAM treatment based on one small study. 6 months is not long enough to discover long-term effects of a toxic drug like AZT.

  30. pec, you really are having difficulty with reality testing. Maybe there are “long-term” adverse effects of AZT. The short-term adverse effects of HIV and AIDS are considerably worse (those effects being death).

    You are correct, only 27 patients received AZT for the longest period. Of all patients receiving AZT only 1 died. Of patients on placebo 19 died. When the p value of AZT not being better treatment than placebo reaches 0.001, it is considered unethical to continue giving people placebo when the outcome is death. What p value would you use to end such a trial?

    If you click on the “see all related articles” link at the bottom of the column of related articles on the right, more articles come up. The next one

    http://www.ncbi.nlm.nih.gov/pubmed/3299090

    talks about toxicity and adverse effects observed in the patients. There were some serious complications. BFD. The complications were manageable and the patients lived.

    AZT was not accepted based on this single small study. AZT was designed to have certain pharmacological effects. It was tested in vitro and in cell culture before it was tested in humans.

    If any CAM treatment modality had the same scientific history as AZT, including theory, laboratory work and finally a clinical trial that was this successful treating something as serious as AIDS the treatment wouldn’t be CAM; it would be first line EBM. No CAM modality has ever had a history like this.

  31. What daedalus said. I would also note that the goalposts are shifting with remarkable rapidity. First the claim was that no placebo controlled studies of HIV drugs exist. There are. Then that there was only one study. A superficial examination of Medline demonstrates that there are other placebo controlled trials of AZT. Wonder where the goal will move next…

    You would never accept a CAM treatment based on one small study.

    Can you name any study of any CAM treatment that has improved survival of a formerly untreatable or barely treatable disease, even in a small study? I can’t think of any, but have not extensively reviewed the CAM literature, so if there are any famous cases, please do mention them.

  32. “First the claim was that no placebo controlled studies of HIV drugs exist.”

    I NEVER claimed that. I said the link I was referred to”

    http://www.ncbi.nlm.nih.gov/pubmed/11322246?ordinalpos=130&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

    had no untreated group.

    After the early apparent success of AZT there were no untreated groups.

    Since the outcomes for HIV infected untreated patients has never been compared to HIV infected patients treated with ARV drugs, you cannot draw an evidence-based conclusion.

    There was little or no research showing AZT was safe and effective over long periods. Showing some promise in a small short-term study was enough. You would NEVER accept a CAM treatment with so little evidence.

  33. Anonymous 6:38, huh? There has never been a CAM treatment with as much evidence as there was for AZT.

    AZT was shown better than placebo to a very high degree of certainty.

    At what p level would you stop the trial and give everyone the treatment that is working best?

  34. A treatment should not be accepted as the standard based on one small short-term study. Especially if the treatment is highly toxic.

  35. pec, what criteria do you use to determine if a trial is “small”, “short-term”, and if a treatment is “highly toxic”?

    What p value would you require before determining a treatment meets the “standard” of care?

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