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When less medicine is more

For years I have ranted about the flaws of medicine, especially when it comes to mental illness and cancer. But my complaints are mild compared to those of Jacob Stegenga, a philosopher at the University of Cambridge. In Medical Nihilism, published by Oxford University Press, he presents a devastating critique of medicine. Most treatments, he argues, do not work very well, and many do more harm than good. Therefore we should “have little confidence in medical interventions” and resort to them much more sparingly. That’s what Stegenga means by medical nihilism.

Skepticism toward medicine was once widespread, even among physicians. In 1860, Oliver Wendell Holmes, Dean of Harvard Medical School, wrote that if all medical treatments “could be sunk to the bottom of the sea, it would be all the better for mankind—and all the worse for the fishes.” Such cynicism faded with the advent of anesthesia, antiseptic surgical techniques, vaccines, and truly effective treatments, notably antibiotics for infectious disease and insulin for diabetes. Stegenga calls antibiotics and insulin “magic bullets,” a phrase coined by physician Paul Ehrlich to describe treatments that target the cause of a disease without disrupting the body’s healthy functions.

Researchers have labored mightily to find more magic bullets, but they remain rare. Most forms of cancer, as well as heart disease, Parkinson’s, Alzheimer’s, arthritis, schizophrenia, and bipolar disorder, lack cures or reliable treatments. Many “widely consumed” medications are “barely effective and have many harmful side effects,” Stegenga writes. Examples include drugs for high cholesterolhypertensiontype-two diabetes, and depression.

Stegenga warns readers not to stop taking prescribed medications without medical supervision. But our health will improve and costs shrink, he contends, if we resort to treatments less often. A 2013 study estimated that more than 400,000 “preventable hospital-caused deaths” occur in the U.S. every year, and as many as 8 million patients suffer “serious harm.” As Hippocrates once said, “to do nothing is also a good remedy.”

The core of Stegenga’s book is his critique of clinical trials. John Ioannidis, a Stanford statistician who has exposed flaws in the scientific literature and whom Stegenga cites repeatedly, asserted in 2016 that most clinical research “is not useful,” meaning it does not “make a difference for health and disease outcomes.” He has also pointed out that “conflicts of interest abound” in medical research.

Industry-sponsored trials are far more likely to show benefits than independent investigations, Stegenga writes. Meta-analyses of antidepressants carried out by researchers with industry ties are 22 times less likely to mention negative effectsthan independent analyses. According to another analysis, company-sponsored comparisons of hypertension treatments are 35 times more likely to favor the sponsor’s treatment over alternatives.

Stegenga emphasizes that he is not anti-science or anti-medicine. Quite the contrary. His goal is to improve medicine, aligning it with what rigorous research actually reveals about the pros and cons of treatments. His thesis should not hearten advocates of “alternative” medicine, which has even less empirical standing than the mainstream. He writes:

“There is no place I would rather be after a serious accident than in an intensive care unit. For a headache, aspirin; for many infections, antibiotics; for some diabetics, insulin—there are a handful of truly amazing medical intervention, many discovered between seventy and ninety years ago. However, by most measures of medical consumption—number of patients, number of dollars, number of prescriptions—the most commonly employed interventions, especially those introduced in recent decades, provide compelling warrant for medical nihilism.”

Stegenga acknowledges that “medical nihilism” sounds grim. Some readers might prefer his more upbeat phrase “gentle medicine,” which calls for less emphasis on cures and more on care, including pain management (although the current opioid epidemic shows that even pain management poses risks). But I like “medical nihilism” because it stings. It delivers a much-needed slap across the face of healthcare providers and consumers, a slap we need to rouse us from our acceptance of the abysmal status quo. If more of us accepted medicine’s limits and acted accordingly, our health would surely improve and our costs plummet.

John Horgan directs the Center for Science Writings at Stevens. This column is adapted from one originally published on his Scientific American blog, “Cross-check.”

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