Why do some good doctors become bad doctors?

In NZ Skeptic 82, John Welch wrote that there was something about general practice which attracts an interest in complementary and alternative medicine (CAM). Is it acceptable for medical graduates with a science degree to be allowed to carry on in this manner? Should we amend the medical registration so they can’t? Is legislation needed to alter the culture-of doctors and society generally? This article is based on a presentation to the 2007 NZ Skeptics Conference.

Society confers upon the medical profession certain privileges, as it does upon lawyers, clerics, JPs and those entitled to issue warrant of fitness certificates. For the past 150 years or so the privileges enjoyed by doctors and those practising within the so-called orthodox health professions, have been granted and maintained upon the assumption that they undergo rigorous scientifically based education and maintain a scientific basis for their entire careers. The privileges can be quite rewarding in monetary and other terms.

We agree that the scope of such rewards implies an added burden of responsibility in understanding the nature of science and the requirements for application of scientific principles to clinical medicine. In modern society that is not as easy as it sounds. What follows is not a defence for doctors who may be failing to meet the assumed standards but rather our perceptions of why, so often, we doctors do as we do. We examine what we perceive to be a subculture which has always been present, but which may now be something of an epiculture.

For several thousand years doctors under various guises functioned independently of governments but not independently of the ruling classes. Various forms of Robin Hood-style financing kept the system going. Science, which essentially disproves current dogma progressively, infiltrated the healing arts. Medical education at university level in its present form dates back about 150 years. Paradoxically, junior doctors at Auckland City Hospital function much the way their forebears did at the Edinburgh Royal Infirmary 150 years ago. Old-style apprenticeships still guide aspirants to the various specialties and subspecialties within medicine. In most of the western world, consultants split their time between private practice, which they regard as a no-go area for government, and their hospital duties which enable them to keep up to date with new ideas and with young people. Conversely, most full-time hospital doctors are employees of the government.

This pattern had its beginnings in the 1790s. The industrial revolution brought social and demographic changes which had catastrophic effects on the health of the community. The politicians, perforce, had to react. Thus began the moves towards what we can loosely term socialised medicine. Third parties came into the doctor-patient relationship.

A crucial event occurred in 1938. Sensing the advance of socialised medicine ideas in Europe, the all-powerful surgeons of the American Medical Association sent a delegation to Europe which met with the surgeons of Nazi Germany, France and England. It was agreed that big insurance agencies, largely owned and controlled by the medical profession but attracting private finance, should be established immediately. The important corollary was that remuneration for the doctors would be on a procedural basis.

Patients would pay for a particular procedural process and not for the time spent in performing it. Such remains the basis for private practice throughout the western world and for much general practice. It is a crucial controlling factor on the way doctors practise and a powerful formative influence on the aspirations of young entrants to the profession. The net effect is that the bigger economic rewards occur outside and separately from the government. Possession of a particular technique, plus some entrepreneurial flair, is good for business.

There will always be some imbalance and mismatch of information between patients and their practitioners. So-called third parties have tried to intervene between patient and practitioner to modify the system. These third party ploys have largely failed, spectacularly in the case of US medicine. In what other industry would a cataract operation of brief duration secure a fee greater than that for key-hole surgery for gallbladder removal involving a much longer duration?

Over the last 50 years medical technology and basic medical science have advanced at the expected accelerating growth rates. What is not so obvious is the devastating effect this has had on general medical practice. A very powerful health-disease oriented industry now operates within the western world. The financial success of the doctors generally has been studied carefully by non-medically qualified people and a parallel or alternative medicine system has mushroomed. Its power is quite obvious in New Zealand when it is faced with threatening legislation based on calls for proven efficacy. The scientific concepts that knowledge is continually changing and must be continually reassessed, and that efficacy should be the basis for change of therapy and professional remuneration, play little part in the world of complementary and alternative medicine (CAM).

Checking a myth

About ten years after the first graduates emerged from the Auckland Medical School there was a widespread myth that Auckland students, having had more behavioural medicine in their undergraduate course, were much better at taking histories from, and establishing empathy with, patients. Conversely, Otago students were alleged to be much better at practical procedures.

One of us (JS) didn’t believe this and received a grant to compare the performance at hospital level of graduates from the two schools. The pervasiveness of the myth was fully confirmed by the consultants, matrons and hospital superintendents who still existed at the time, and by many of the former students themselves. However, I did not restrict my study to gaining the opinions of administrators, chief doctors and chief nurses. I went to telephone operators, the women in charge of the residences, laundries, kitchen staff, orderlies and charge nurses on the wards. I knew many of the Auckland graduates on an individual basis pretty well. What pained me deeply was learning that bright young people, both men and women, whom I had known fairly well as undergraduates and whom I regarded as sensitive, intelligent and obviously well fitted for medicine, had turned into arrogant, sometimes rude, aggressive, insensitive, awkward creatures who often were destructively disruptive of team functioning. Conversely, many of that group were highly successful in terms of acquisition of postgraduate diplomas and remunerated positions. I felt my own judgment had been severely challenged in terms of my starting opinion of these emerging graduates. I went back to Auckland with my tail between my legs but decided to analyse the situation further, knowing also that the myth was a myth.

Emerging pattern

A clear pattern emerged between the aberrant behaviour as I saw it of these young people and their attachments to clinical teams in the fifth and sixth years of their training. This clear-cut relationship involved role modelling, inspired somewhat by the personality of the emerging graduates themselves. More importantly, role models of the aberrant group demonstrating what I thought was unsatisfactory behaviour, had been adopted particularly from some surgical specialty teams led by powerful personalities who demonstrated essentially egotistical, flamboyant and at times outrageous behaviour, which was accompanied by affluence and considerable medico-political power.

Within North America and the British Commonwealth, and to a large extent in Europe, based on the leadership of a few doctors, patterns of medical profession behaviour have survived by resisting waves of political pressure from sociologists, politicians and economists. The great medical registration Acts of mid-nineteenth century Great Britain, are touted as wonderful examples of the altruism of the medical profession. But the transcripts of the Westminster proceedings and the antics of the medical profession at that time, particularly those of some prominent surgeons, reveal how the medical profession adroitly preserved its position. Conversely, the divide between general practitioners and emerging specialists was ensured. Nevertheless, a great deal was gained for the population generally, in terms of paving the way for more scientific application to the practice of medicine. In 1945, with the introduction of the NHS, the specialists or consultants in Great Britain again feathered their nest at a time when the whole framework of state-supported practice was changed. In the late 1990s matters came to a head when for the first time a general practitioner was made Chair of the Greater Medical Council of Westminster. Things have changed since then but, in our opinion, the essential reform steps have yet to be undertaken.

Answering John Welch

We have now set the ground for our first response to John Welch. No, it is not acceptable for medical graduates with science-based degrees to be allowed to carry on earning considerable sums from some forms of CAM without analysing or acknowledging what they are doing, and all practised with apparent conviction that something unique or specific is being proffered. In so doing they have abandoned science-to what extent depends upon one’s perspective.

If such practice is reasonably widespread, how has this come about? We would argue that the environment into which students are released and the power of particular personalities can override what teachers believe they have inculcated into the minds of their students. In turn this means that the teaching has not been powerful or sustained enough, to carry sufficient clout. In keeping with changes in wider society, students are becoming more demanding of Faculty. Students are demanding more facts and less waffle. ‘Facts’ are equated with ephemeral knowledge, itself a sacrosanct entity which is essential for passing various hurdles. ‘Waffle’ refers to sections of the curriculum devoted to community issues, public health, communication matters and so forth. We are not aware of any satisfactory studies to back our belief that students in general are not particularly interested in lectures on the nature of science or induction into Bayesian concepts to which they theoretically subscribe. We know that many students still believe it is the business of government and administrators to find the money and resources for them to exercise their particular forms of practice, and thus for them to expend those resources freely and independently of audit or censure.

What do patients want?

The concept is abroad amongst some students and younger doctors, that patients always require something tangible from a practitioner and their problems cannot be dismissed without some tangible transaction. Students in turn interpret this as the need for them to manipulate highly visible props for reinforcement of the placebo effect.

When general practitioner incomes fall, offering homeopathy or chelation for a fee becomes attractive, particularly within a culture wherein needs and expectations are being expressed increasingly by members of a public who are increasingly influenced by advertising, non-scientific articles and spurious claims.

CAM at Med School

In the Auckland School of Medicine there are brief sessions devoted to the topic of CAM. The general approach offers the students a broad brush introduction to principles in common forms of CAM, why these appeal to the public, how the efficacy could be judged, and some attention is paid to identifying potential interactions with orthodox medicine. The topic is introduced in Years 2 and 3, and reviewed in Year 5. Given the present situation we believe there is considerable scope for providing a more detailed history of CAM within the curriculum, including scientific criticisms thereof, together with reinforcement at other stages of the course, concerning the nature of the conflict between science and non-science, the role of the doctor’s personality and projection thereof, and what they are contributing to the therapeutic interaction. In the New Zealand Medical Journal of May 2007 Rosemary Wyber and Tony Egan set about elucidating the views and experiences of a group of general practitioners and a group of current junior doctors one or two years out from graduation. To quote: “… A poor relationship with medicine is thought to be an area of considerable unconscious influence of role models. This may contribute to the well documented decrease in idealism during student and early clinical years.”

In the same issue, Tim Wilkinson, the Associate Dean of Medical Education at the Christchurch School of Medicine & Health Sciences, drew attention to the importance of getting the learning environment right. He wrote: “If learning occurs first within an environment of trust and respect … good role modelling will mean effective learning will not be undermined.” This line of reasoning is further reinforced in the same journal by an article by Kathleen Callaghan, Graham Hunt and John Windsor from the University of Auckland. They draw attention to failure of medical training to provide time for exposition of the non-technical aspects of competency.

We agree with their conclusion that professional training programmes need to be radically revised. Professional competency needs redefinition. Such definition must be team-orientated. Attitudes and aptitudes

Of relevance to John Welch’s first question is an issue raised by Callaghan and her colleagues. “Should there be testing of relevant attitudes and aptitudes prior to selection for postgraduate training?” Again, should we select prior to undergraduate training for a wider array of attitudes and aptitudes which would then be integrated and progressively monitored throughout undergraduate training, to ensure a differentiated work force of doctors based on society’s needs? These authors suggest some fundamental questions should include, “What are the patient outcomes that society expects us to deliver?” And “What are the professional competencies required to ensure that these outcomes are achieved?”

Attitudes towards (and use of) CAM in New Zealand were also studied by Poynton and colleagues in the NZ Medical Journal (2006). They found that the number of general practitioners using complementary and alternative medical therapies had decreased but the number referring patients to the unorthodox system had increased. They called for increasing information on CAM to be included in medical education and for attention to earlier research.

A call for reform

A Lancet editorial by Baker in 2005 stated that the time had come to explore the need for a major reform of medical institutions to make them fit to sustain professionalism and respond to the changing expectations of society. In so responding the medical profession and those who educate its entrants needed to have sound perspectives and the ability to challenge some of the false expectations within society. A key point in relation to false expectations is the utilisation of the placebo effect by both orthodox medicine and CAM. When properly handled, there is general recognition that the placebo effect is a boon to busy clinicians and their patients. However, such responses vary considerably between different diseases. Time heals a great deal. Some chronic diseases remit spontaneously. The first thing we educators need to do is to emphasise and demonstrate to students the natural history of disease. In so doing we need to place that in the context of the placebo effect and point out that such effects are notoriously fickle and may occur on one occasion and not on another within the same patient. Use of placebo effects varies across disciplines. We need to point out that large fees are not necessary for inducing a maximum placebo response-but time spent does require reasonable recompense nevertheless.

Scientific medicine and personal influence

Dr John Ellard, a prominent psychiatrist in Australia, has summed it all up in an article entitled, What can be learned from a curing of warts? To quote him: “… in most therapeutic situations there are two important aspects: scientific medicine, and the influence of one person on another. To ignore either is imprudent because the best outcome will be obtained only if both are considered … many remedies work quite well without a scientific basis. My argument is that one should strive for the best of both possible worlds-the greatest benefit from scientific medicine … and the greatest benefit from the healing power of concern for the person. Concern about the disease is not enough”. Moreover, adherence to medication or placebo was associated with lower mortality rates in a Canadian survey of 21 studies; patients’ psyche and personality are very much factors in determining outcomes.

The important point about Dr Ellard’s comment is that the mystique element is removed from the doctor-patient interaction associated with placebo effects. We believe there is no point in studying any mythical homeopathic mechanism, for instance, independent of the placebo effect. Observations of such therapies should be submitted to the same disciplines as evolving treatments in orthodox medicine. They should be controlled for consequences of the passage of time, that is of natural history, observations should be standardised and raw data made available for scrutiny by independent researchers at no extra cost to the subjects of such new (or old) treatments.

Social contracts

In reviewing social contracts much will be required in public education through public involvement and, to some extent at least, through lobbying and other manipulations of the legislature and the legal environment. Increasingly it will be in the interests of our nation as a whole, to review remuneration of time spent by health professionals and what balance should be set between expenditure within essentially a state-run system versus the proportion of national resources expended within an uncontrolled private sector. We believe some curbs will be required in future concerning irresponsible actions within the media, but unless the medical profession and public perceptions alter it will be impossible to develop a common culture and we will all fail together.

Within our present structure of cultures lie the medical students we select for the Otago and Auckland schools. The late Frank Haden pointed out at a previous Skeptics conference in Christchurch: “a doctor told us matter-of-factly that seven percent of the school’s 1997 fifth year students believed in creationism.” There is work to be done. We face an aggressive, burgeoning non-science or anti-science culture. Some of our students lie within awkward subcultures and some enter these after graduation. In finishing, we quote a 1995 Lancet editorial. “The intellectual strength of science lies in its essentially subversive character.” That same editorial quoted Freeman Dyson: “There is no such thing as a unique scientific vision … science is a mosaic of partial and conflicting visions. But there is one common element in these visions. The common element is rebellion against the restriction imposed by the locally prevailing culture.”

To this we can add the conclusion of a paper titled Health Delusions, written by Denis Dutton in 1988. “I am disturbed by a Listener editorial not long ago on the topic of alternative medicine which has gone so far as to call for government funding for fringe medical services. And this editorial ought not to be dismissed as an insignificant aberration: in the present user-pays climate of medical policy decisions it is possible that there will be increased pressure to turn our back on expensive, science-based medicine in favour of popular but worthless pseudoscientific placebos. I think it is imperative that health professionals throughout New Zealand work to resist such pressures. Our stretched public health resources must be directed towards valid, effective science-based care. Anything less will prove expensive and dangerous.”

List of references available from the editor.

The Global Messenger Hoax And The Misinformation Economy

At last year’s conference, John Scott spoke on the problems of mixing misinformation and medicine.

Early in my medical career I became aware of the enormous distorting forces which operate upon science in the real world. In my field the forces were those of Quaker Oats, Kellogg, Sanitarium, the diary industry, the AMA, elements within the cardiology camp, and the tobacco giants. I became an interested observer of some enormous investments in dubious research projects, many of which could only be termed con-jobs. More particularly, I realised that we scientists were very human creatures.

Together with many of my colleagues I plodded along trying to inculcate into oncoming generations of medical students a genuine understanding of scientific principles and methods. To be frank, my generation of teachers has failed, certainly as far as the bulk of medical graduates is concerned. Events over the past year in England, Europe and New Zealand have rammed that point home, often in painful ways, as far as I am concerned.

I do not wish to be seen to disparage many of the achievements of scientific and technological medicine over the past thirty to forty years. They have been massive. However, other huge investments in the health-disease industry deserved to be challenged and remain in that situation.

The central message so far is not news to this society. Bill Morris gave a paper at the Palmerston North meeting challenging much of the classical diet-coronary heart disease hypothesis. His voice was about as lonely as mine at that time. Science ultimately makes advances by gaining improved understanding of mechanisms. There is nothing wrong in doing one’s best with available knowledge until one obtains comprehensive understanding of a particular situation.

Coronary artery disease and arterial disease generally present very complicated problems. Fortunately and unfortunately, in an exquisite paradox, arterial disease is a very general phenomenon and becoming more so as countries become steadily more affluent.

There is enough knowledge to make a reasonably firm statement of dogma, that the causation is multifactorial and represents an interplay between environment and one’s genetic endowment. This statement doesn’t help a great deal about developing techniques for elucidating mechanisms. It does, however, provide wonderful protection for less competent scientists and technologists, and certainly, for industry generally.

New Technology

The cholesterol-saturated fat-diet-arterial disease hypothesis really took off when the 19th century concepts concerning the potential of computers were made possible through the development of transistors and printed circuits. In turn, epidemiology was provided with a tool it had needed. The autoanalyser had also been invented and thus mass biochemistry was now possible.

What amounts to an industry with a turnover through the decades of trillions of dollars was really set alight by a gentleman called Ancel Keys. He undertook studies in Europe linking what amounted to death certification and some relatively crude morbidity data with the local diet and estimates of cholesterol levels.

Here we get into what I term the “global messenger hoax”. On a simple arithmetical biaxial plot, Ancel Keys’ data, from his various countries, was the traditional dog’s breakfast. Subsequently one of his senior technicians, who was extremely troubled by what happened, published the truth.

In turn the technician’s article was immediately suppressed pretty effectively by the scientific juggernaut which had developed around this particular health-disease industry. Ancel Keys had selected a series of points which produced a straight line on a semilogarithmic plot or a gentle smooth curve on semilogarithmic axes.

I was aware of this at the time but didn’t get very far in quoting it, although, to his credit, the later Sir Edward Sayers accepted that Ancel Keys had at least been naughty. However, eventually a very prominent American nutritionist and professor of medicine, Dr Feinstein, published the original material plus Ancel Keys’ simplified extrapolated data which had set the whole bandwagon rolling. Feinstein came into the scene too late. He was too big a Don Quixote to be rubbished, so he was therefore largely ignored.

Now there is nothing particularly unusual about all that. As is eminently predictable, history is catching up with the epidemiologists who have continually reinvented the Ancel Keys wheel. Basic scientists, particularly anatomists, pathologists and immunologists, with their analysers and biochemistry, have begun to get at the common pathways upon which genetics and a complex environment interact to produce arterial disease. The gross simplifications have been exposed. Interestingly, however, the process continues of twisting results of recent research to fit the theory at each stage of the wheel reincarnation.

Alternative Interpretation

Most of you will know about the statin drugs which are very powerful reducers of cholesterol levels. Probably a majority of my colleagues believe that the advent of these drugs and their testing on a massive scale by people, including me, has vindicated the cholesterol hypothesis.

However, it might interest you to know that Brown and Goldstein, now working in Southwestern University of Texas, have a huge group of scientists and technologists exploring alternative interpretations.

If it was possible for physicians and epidemiologists to remove their dogma spattered spectacles, they would see what is obvious from most of the large statin trials, particularly the much hailed 4S or Simvastatin study. The effects of morbidity and mortality were proportionally just as great for the group at the bottom end of the scale of cholesterol elevation as they were for the top end.

If one thinks that through carefully and reanalyses the evidence, something else is going on than mere lowering of cholesterol and low density lipoprotein. There is no real surprise in that, when one looks at the nature of the intervention in the cholesterol synthesis pathway, and links that to the ubiquity of cholesterol as an essential structure which holds many biologically important molecules in a particular spatial pattern.

Cholesterol is involved in many biochemical processes and synthetic pathways. The statin drugs do many more things than just lower elevated cholesterol. But the message proclaiming the dogma is out there, and the messengers are not going to change their message in a hurry without carefully considering the shareholders’ interests. After all, the drugs do have a demonstrable effect and are eminently marketable even on the basis of partial evidence.

That brings us up against the real problem and my choice for the title of this talk. We live in an age of misinformation. Politicians seem oblivious to that as they play gleefully with the bubbly toy of the knowledge society concept.

Political games not withstanding, we are all in on this mass-deception exercise. When I thought about applying to the then Mr, now Sir Douglas Graham for legal aid to support the skeptics in a crusade against the pervading partial truths and cunning deceptions, I realised that he probably would remove his pipe temporarily and mumble something about the stability of societal constructs and the impoverishment of lawyers generally.

When more recently I wondered about approaching the Hon Tony Ryall, I realised that I might receive a lecture on fundamentalist thinking. He might use the biblical quote, “You who are not for us are against us.” Moreover, if I took my protests elsewhere I would be rapidly caught up with various religion-based aphorisms. You seek to be a prophet in your own country, haven’t you read the bible?

Shooting the Messenger

These musings sent me off on another trial as the green lipped mussel saga developed. I happen to know a lot about these tasty beasties, because work on them was undertaken in the Department of Medicine in Auckland during the time that Derek North and I were HODs.

Once again, it’s the messenger business that interests me. I happen to believe that Susan Wood is a more astute and intelligent anchor girl than Holmes, allowing for gender-bending bias. However, it rankled me that she and the editor of the New Zealand Herald both came out with the all-innocent line – “Why attack me, I’m only the messenger,” to paraphrase things. A spokesperson for the Ministry of Health understood that he was being snowed by Susan Wood but didn’t quite get his counter-attack launched correctly. The Herald seems to have got away with it more or less completely.

However, there is a huge message within that message. The media are not just the messengers. They are an integral part of the process of the misinformation economy. New Zealand is, for at least half its population, a comfortable consumer society, seemingly happy to buy more than it can afford. The United States is going the same way as evidenced by this month’s trade deficit.

If we analyse that situation further, it becomes pretty obvious that what might be termed scientific truth, in itself certainly not an absolute or a constant quality, is now a debased commodity. The concept of quality of information which members of the Skeptics believe to be an essential prerequisite for intelligent human advancement, is held in contempt by key players in the global economy.

Evidence of Efficacy

It is all very well for the Medical Council of New Zealand to pronounce that there is no difference between orthodox and traditional or nonorthodox therapies, their common attribute being that any claims they make shall be based upon evidence of efficacy.

That sounds fine but it flies in the face of reality. Unfortunately, the failure of people like me as medical educators receives poignant testimony from the increasing use of acupuncture, homeopathy and so forth, by so many of our graduates.

Moreover, the status of a critic of these mixed practice habits is weakened by the continuing paucity of sound justification for many so-called orthodox practices. However, thanks to the financial seduction of the messengers, downgrading of science is now a fashionable global activity.

Occasionally I tune in before the 6pm TV1 news and there is the lady representing Blackmores coaxing me into upsetting my gastrointestinal system with slippery elm and to exposing my nervous and renal systems to potential chaos as I ingest mixtures of herbs, some of which contain quite toxic compounds.

I have carefully avoided quoting from the genetic engineering debate but you all know that I am heavily involved in that as president of the Royal Society and in defending science and technology. In particular that society is trying to ensure that information across the spectrum of opinion is made available to the New Zealand public.

We have done a bad job in this, because we failed to estimate the strength, political nouse, and financial capacity of the opposition, that is, of the anti-biotechnology anti-genetic engineering lobbyists, particularly in Europe, England and now New Zealand.

Is this little diatribe of any relevance? I believe there are two important aspects to the great global messenger hoax and the misinformation economy. A lot of harm is being done to people who are not in a position to understand what is happening.

As soon as I make such a statement, I am immediately assailed by the various groups which benefit financially, or in terms of personal status and so forth, because I am becoming paternalistic in a traditional manner and seeking to impose my restrictions on their freedom of choice. However, let’s take that a wee bit further.

To me it is heartening to see Sandra Coney and Robyn Stent opposing one another publicly over the issue of patients’ rights in relation to Lyprinol. I further applaud Dr Pippa MacKay in joining the fray in the New Zealand Herald. I suspect that newspaper does feel guilty about its part in the $2 million one-day killing, but that guilt won’t last for long. Why then are these issues important?

Vaccination Alarms

In 1998 reports began to circulate that measles, mumps and rubella (MMR) vaccination might cause autism, possibly through a mechanisim involving changes in bowel function.

There were immediate notes of caution sounded but they were largely ignored. It was pointed out that the reported cases might have been due to what is termed temporal coincidence. There was certainly no convincing laboratory evidence for the contention. A specially convened United Kingdom Medical Research Council committee found the so-called clinical evidence unconvincing.

However, the media messengers got into gear and there was a definite drop in acceptance of MMR vaccination in the United Kingdom. That has spilled over into New Zealand and added fuel to the anti-vaccination campaign here.

This is what I mean by people being harmed by what I have termed the global hoax of purveying partial or pseudo scientific information, to gain readership or viewing numbers for the profit of the moment or for political advantage. Infants and children are in no position to give informed consent, their parents are well placed to be misled.

Information Ignored

I use this particular example because the press internationally ignored information available at the time of the initial sensational reports, which indicated that the measles virus was not the mechanism for the observed cases of inflammatory bowel disease (IBD). There was thus selective reporting for purposes of gaining sensation.

I believe that in June 1999 The Lancet laid the matter to rest with the advent of further information. The Lancet also says in its edition of June 12, page 1988 that:

Will the scientifically sound and essentially ‘negative’ results published this week garner the same media and public attention as the initial report of the MMR-autism hypothesis? It is unlikely, as evidenced by the renewed media frenzy last week in response to another report by the group that proposed the hypothesis. This report was of an increased risk of inflammatory bowel disease among individuals who had naturally acquired measles and mumps within one year of each other. The study had no data on MMR vaccine and the investigators specifically stated that they did not find a significant relation between monovalent measles vaccination alone and later IBD. Yet the popular media trumpeted the study as providing evidence that MMR vaccination may cause IBD. In such an environment it is critical to strengthen vaccine safety monitoring systems and risk-communication strategies to maintain public confidence in immunisation.

Lancet Editorial Comment, by F De Stefano and RT Chen, 1999, Vol 353, pp 1987-1988

Thus I believe the first important aspect of all this is that the misinformation distribution process can be harmful.

The second important aspect relates to what the whole process tells us about ourselves as a collective society. In a New Zealand which is seemingly increasingly non-numerate to an effective degree, and increasingly less literate in the classical sense, we do face a problem and may need more than legal aid to save our society from contemporary ridicule emanating from better educated international competitors, or worst fate of all, transformation into a nation dominated by a media worshipping cult.

I don’t blame the media for what is happening – I blame ourselves for our failure to anticipate the consequences which automatically ensue when the information technology explosion hits an unprepared, untutored, non-critical society.

We skeptics do have a role – we need to decide how to change the pattern of which I am, I believe, justifiably critical, such that New Zealand can reach democratic decisions on a basis of roundly presented, soundly analysed, best available information.

Can we, the skeptics, help disprove the hypothesis of HG Wells who wrote in 1920:

Human history becomes more and more a race between education and catastrophe.


This is a copy of a presentation given to the New Zealand Skeptics 1995 Conference in Auckland

When Denis Dutton asked me to prepare some comments on this topic he gave me a very wide brief covering, “any aspect that strikes your fancy”.

Since he has left the definition and the territory to me, I will indulge myself, knowing that any remark from here on will be controversial.

Over the same time I had the privilege to witness one of history’s recurrent twists, whereby there is a recapitulation of medical behavioural patterns which can be expressed in Darwinian terms. This has provided some of us with the opportunity to observe the consequences arising directly from the ebb and flow of irrational human behaviour.

In the late 1940s I set out to become an engineer, but I meandered into medicine. I retain some interests in the area of the physical sciences and I think I understand why a 747 flies and usually does not fall to bits on take-off or landing. Such deep insight allows me to perceive the distinction between the functioning of an aircraft engineer and that of a traditional doctor. It is mandatory, as well as reasonable, to test the wings of a proposed new aircraft to the point of destruction in an aeronautical laboratory. In most countries, similar destruction of a human being in a physical or psychological sense is forbidden, or at least not discussed openly in public.

The distinction between the two situations does not stop there. In the former instance, a physical object is being tested by engineers and scientists using a fairly soundly based set of facts, many of which will not change as knowledge evolves. However, errors can occur in both the design and testing of an aircraft wing due to the fallibility in human terms of scientists and engineers. Conversely, in the case of interactions between orthodox doctors and patients or clients, the interactions involve two sets of human behaviour. The nett effect is that at least in terms of ephemeral knowledge, there will be a much greater measure of certainty in the case of the aircraft wing testing than there will be in any health professional-patient interaction.

All that seems very obvious, but I can assure you it is not obvious to many who design and manage health services in various parts of the world, nor is it understood by many orthodox clinicians.

These considerations do, however, lead on to recognition of one perspective through which pseudo-medicine can be defined. In discussing pseudo-medicine we are really addressing a pattern of behaviour which is incongruent with principles common to sound aircraft engineering and sound allopathic medicine. Because a set of physically determined factors imposes a very firm set of disciplines upon the aircraft engineer, he or she operates within definable, and fairly closely defined, sets of constraints.

That is not the situation as far as medicine is concerned. An aircraft wing talks back to its designer by performing efficiently or failing. A patient or client exhibits an enormous range of responses to the propositions of a health professional, who operates within loose constraints, extremely wide boundaries and enormous levels of tolerance. Failure to observe what we may loosely term the laws of nature in relation to aircraft wings induces clearly observable and immediate consequences. Errors of logic and application of scientific knowledge or the indulgence of magic and quackery can persist for centuries in terms of medical practice.

My first point then is that the aircraft engineer is brought face-to-face with the realities of certainty and uncertainty from the outset. Such is not the case for health professional patient interactions.


When confronted by uncertainty, a person who has a sound understanding of rationality and science acknowledges that doubt and ignorance are facts to be accepted and confronted. If we pause to think about that, hopefully a majority of us within medicine will rapidly realise that John Kenneth Gailbraith was correct when he said “when people are least sure, they are often most dogmatic”.

That idea can be extended by the observation that many who are superficially extremely confident suppress their doubts and uncertainties through extremely assertive behaviour and exposition of dogma. Sometimes they are exposed, as happened to Margaret Thatcher when caught on the hop by the BBC, who perceived she really did not know what to do about the political future of Hong Kong after 1997. “…now, when you say that, you don’t have to go into, to say, well now, precisely what is the nature of this link and the nature of the law and so on…”2

The problem with the Thatchers of this world is that during their predominant period of confidence, while they suppress any dangerous urge to admit doubt and uncertainty, they can inflict devastating damage on huge chunks of society and humanity generally. The consequences may be disastrous for many of us and not just for Argentinean sailors.

That arch sceptic, the late Petr Skrabanek, in a signed Lancet editorial entitled “The Epidemiology of Errors”, quoted Lewis Thomas: “A good deal of scientists, many of them in the professional fields of epidemiology and public health, have never learned how to avoid waffling when yes or no are not available, and the only correct answer is, I don’t know”.1 Pseudo-medicine arises when doctors, particularly, are confronted by a problem for which there is no clear-cut answer. Unfortunately in such situations, many doctors while swearing allegiance on the altar of medical science, move into the Thatcher mode. The practice of pseudo-medicine is based on that phenomenon.

Contrary to the viewpoint of a majority of the public and the media, and against the enthusiastic prophesy of many health professionals, areas of uncertainty are going to become more extensive rather than less as we move into the 21st Century. As technology becomes more sophisticated, complex issues concerning its application are going to raise increasing areas of uncertainty. It is not difficult to predict that there will be an increasing tendency for impetuous action to be taken as anxiety levels increase in the face of uncertainty.

Conversely, there may be a decline in recourse to consultation on the basis of “I don’t know, can you help?” Systematisation of doubt, and suppression of uncertainty lead to indulgence in such practices as homeopathy, chelation and a variety of magical and quack practises. I am not going to go into those areas in detail because they have been well traversed at previous annual meetings of this Society. Rather I want to spend the remaining time indicating the pervasiveness of the problem.

If we put aside the really major health disease problems of society based upon deprivation, economic inequality, hopelessness, loneliness and so forth, we are left with the impact upon society of the chronic degenerative diseases of bones, joints, the cardiovascular systems and cancers. These are the happy hunting grounds of pseudomedicine. The operation of total hip replacement has long since passed the equivalent of the testing of the 747 wings, and is now a standard procedure with sufficient experience behind it to make predictability of application to particular people reasonably certain. That does not mean that a host of other factors are not relevant to the decision whether, when and how to operate on a particular patient and to decide who pays to whom how much.

By contrast, the pain relief to be offered to the person on the increasingly lengthening waiting list for a hip operation provides a fertile ground for the exhibition of pseudo-medicine. Physicians like me do not have ideal pain relieving remedies available for prescribing to such patients. Chronic conditions wax and wane in intensity and it is very difficult to match the interplay of useful and dangerous effects of chronic pain management by drugs, against risks of death, disability and a host of economic factors.

The temptation is always there to indulge in the potentially legitimate use of placebo effect, maybe honestly at first with full understanding of what one is doing, and then to slip into the realm of magic. The boundary between rational therapy and pseudomedicine is very fine, and the width of that boundary varies considerably between one realm of therapy and another and between one doctor and another.

My concept of pseudo-medicine, therefore, is that doctors indulge in the practice when they stop saying, “I don’t know”, stop recognising uncertainty, and substitute false, self-deceiving action based on phoney certainty, backed by great enthusiasm and stern dogma. The euphemistic term “art of medicine” is then applied to this particular brand of practice. The words “art” and “medicine” are simultaneously debased.


Commencing early in the nineteenth century, what has been termed scientific and therapeutic nihilism developed initially in France. In the late 19th Century, influential figures from North America and England, including Sir William Osler who typified both environments, threw their weight behind the therapeutic nihilistic movement. This involved a sceptical approach to the practices and remedies of traditional medicine, and called for the application of rational study and controlled observation of the natural history of disease and its modification in various ways. There was considerable opposition to Osler. Rationalism, scepticism and the scientific method itself, are not immune to rigorous querying from a variety of viewpoints. All can be converted into new forms of religion and all are subject to phases in development.

It took about a hundred years for therapeutic nihilism to demolish significant sections of the old pharmacopoeia, continuing use of which was justified and dignified as being part of the art of medicine.

Earlier in the talk I referred to the interaction of two sets of behaviour when doctor meets patient. History is repeating itself at present as the boundaries where medical science and human behaviour meet are becoming a major topic in the more thoughtful pages of the New England Journal of Medicine, Lancet, BMJ and so forth. Interestingly, the predominant theme in this new wave of medical literature centres on the problems of uncertainty.

Jonathon Rees in the BMJ puts it this way. “For any activity dependent on new knowledge, as medicine is on science, the future is uncertain simply because new knowledge always changes the rules of the game. But even if we could dream this problem away, our guesses of the future will be in error because we continue to delude ourselves, outside the laboratory at least, that we understand the present…”3 Herein lies another basis for pseudo-medicine. Heath professionals like to feel confident and to project confidence in terms of their relationships with patients. Pseudo-medicine flourishes on the basis of apparent confidence exhibited by the professional. The stage is being set in my opinion for an increase in the practice of pseudo-medicine.


During the 1960s, 70s and 80s there was a wave of revulsion directed against orthodox medicine and particularly to its perceived power. To some extent the evils attributed to the atomic scientists spilled over into public attitudes towards orthodox medicine. What was perceived as unholy power held by the medical profession was seen in terms of a citadel which should be destroyed. We saw the revival of naturalism, herbalism and a return to various magical procedures. One of the major textbooks of so-called holistic medicine claimed restoration of the theory of transmutation of the elements whereby sodium was converted to potassium by plants.

The attack was unconsciously, and by some cynical entrepreneurs consciously, directed at the whole concept of therapeutic nihilism. The wash from this revolution lapped on the thresholds of medical schools initially, and then penetrated the corridors of academic medicine. To the horror of people like me, graduates of our young School of Medicine began openly to practise homeopathy and chelation.

I analyse this situation as being due partly to the failure of us as educators to prepare students to handle the avalanche of evolving knowledge in the fields of biochemistry, molecular and behavioural medicine. We have been overwhelmed and have not known how to handle the situation. Our students have entered a world in which monetarism has gained the ascendancy and they see a desperate need to make a living. Those who choose not to become technocrats, replacing hips and removing cataracts, are the most vulnerable. Many of them have already succumbed. Moreover the ramparts of the citadel have been breached in more significant ways.

Our students face the usual mixture of myth and reality which typifies the real world — we have not prepared them adequately to confront this reality and provided them with teaching to handle the situation calmly and rationally.

There is a current vogue for insisting that doctors must model their approach to patients upon so-called “evidence-based” medical practice.4,5 The general concept implies that resources of the State, in particular, should only be expended in those areas where there is so-called objective proof that expenditure will significantly influence the natural course of a disease process. Impetus has been given to this movement through a failure of classical epidemiological approaches to produce clear-cut answers for handling the problems of middle and old age.

Over the past two to three decades, so-called scientific medicine backed by exhortations of academia has persisted in traversing the pathway so heavily criticised by Skrabanek and others. This trend has to some extent been driven by a need for resource acquisition for some sections of medical epidemiology. Disciplines such as cardiology have been happy to help create and then support a mirage through which scientific medicine is seen as responsible for releasing an accelerating series of miracles which will ultimately bring lifelong happiness to everyone. When confronted by the failure to deliver to the masses, sections of these same disciplines, like clinicians, have resorted to pseudo-science that dangerous ally of pseudo-medicine.

Rather than confronting politicians and the public with a clearly defined list of uncertainties, probabilities and areas of ignorance, as David Naylor from the Institute for Clinical Evaluated Sciences in Ontario has pointed out, they have “continued to produce inflated expectations of outcomes-oriented and evidence-based medicine.”5 Following these pathways, they have resorted, not to metaphysics or alchemy, but rather to meta-analysis and leaps of faith which are presented as scientific truths.

The Real Culprit

As Skrabenek has pointed out, the real culprit in all this is “risk-factor epidemiology”. This brash young infant amongst the medical sciences has continued to feed information and misinformation into the media. To quote Skrabenek again, “by the misuse of language and logic, observed associations are presented as causal links”. He further points out that “risk-factor epidemiology relies on case-control or cohort studies without rigorous standards of design, execution and interpretation, even though such studies are susceptible to at least 56 different biases. … How should one remedy this state of affairs — bigger studies, better measurement of risk factors, more complex statistics? Statistics are no cure for the faulty paradigm of risk-factor epidemiology.”1

It is in these areas that pseudo-science has aided and abetted what I perceive to be a particularly dangerous form of pseudo-medicine. It is in these areas that I perceive the most significant breaching of the ramparts of the citadel of scientifically based medical practice.

How has this come about? I believe it derives from the attributes of human behaviour stressed in the earlier part of this talk. Faced with failure to reach their objectives within a particular time span, many working in cardiovascular, cancer, and degenerative diseases have chosen to cope by denying areas of ignorance and uncertainty. Unfortunately they have gone further and have moved the goal-posts when it suited them. They have extrapolated, simplified and at times gone even further.

An obvious example to quote is the famous Lipid Research Clinics Study referred to in a paper at Palmerston North last year. In this study a somewhat unpleasant drug called cholestyramine was used to treat North American men held to be at particular risk from coronary artery disease due to elevated blood cholesterol levels. Extrapolation from that study was quite extraordinary and media manipulation of enormous magnitude was employed to preach a message intended for the masses when the facts were that such extrapolation was invalid for women and for the great bulk of the population.

You will all probably believe, correctly, that strict standards should apply to evaluation of both old and new therapies. It is a truism that anything short of randomised double-blind trials is regarded by proponents of evidence-based medicine as providing an unreliable base upon which to proceed. The problem is that these worthy objectives are being distorted and the public is not being given a transparent account of the problems.

Hormone Replacement

A classical example at the present time would be the largely male-determined dogma that hormone replacement therapy for post-menopausal women cannot be justified in terms of evidence-based medicine. The pseudo-medical pronouncements in this instance have a very complex background which is not usually presented. HRT in terms of scientific literature has concentrated almost wholly upon the fact that women after the change-in-life tend to catch up on men in terms of manifestations of atherosclerosis. There have been no published results from major double-blind prospective clinical trials of oestrogens alone or oestrogens combined with progesterones testing whether or not this therapy retards the appearance of myocardial infarction (coronary attacks) in post-menopausal women.

Prospective trials have shown that oestrogens make women more comfortable in terms of their nether regions, their skin texture and preservation of femininity itself. There is some soft evidence that osteoporosis may be retarded amongst woman taking HRT. Thus the pseudo-medicine proponents of evidence-based medicine who concentrate solely upon one aspect of hormone replacement, that of the cardiovascular effects, are not indulging in true science.

As Naylor has put it, we live in the era of chronic and expensive diseases. “Until the ongoing revolution in molecular biology pays more concrete dividends, we shall be muddling along with what Lewis Thomas characterised as half-way technologies. However medical muddling is a profitable business…”5 It is profitable for research groups, for industry and particularly for the exponents of pseudo-science and pseudo-medicine.

False Prophet

However it is more complicated than that. The general assumption by the practitioners of pseudo-medicine is that more, and what they term better, data will dispel uncertainty in medical decision making. Those who say these things seem unable to learn even from recent history. Those who put their faith in meta-analysis are following a false prophet. Take the case of magnesium in treatment of myocardial infarction. A meta-analysis published in 1993 is entitled “Intravenous magnesium in acute myocardial infarction. An effective, safe, simple and inexpensive intervention”.6 Two years later, results of another mega trial showed that magnesium was, if not totally ineffective, only minimally so in treatment of myocardial infarction.7 Resorting to big numbers will not necessarily solve problems from which the pseudo-medicine proponents are seeking to escape nor will it satisfy the absolutist neo-nihilists.

The current vogue for meta-analysis has arisen from a problem clearly recognised by both impeccable medical scientists and proponents of pseudo-medicine. This is the sheer cost of answering key questions based upon hypotheses propounded in relation to chronic diseases. Because genetic endowment heavily influences the differences between us, manipulation of the environment, including our internal environment, through drugs or diets will usually produce gains at the margin, which are usually minimal.

Blunderbuss therapy requires treating of the masses, many of whom will not benefit, while others are harmed by the proposals. The passion for evidence based medical practice, given our current range of technologies, must make recourse to fairly desperate measures. Thus meta-analysis has become big business. Like is not being lumped with like. Little lumps and big lumps of data are being gathered together by various groups beavering away upon the basis for their own particular perspectives, all seeking to justify their particular beliefs which are promulgated as gospel to an eagerly awaiting public. Unfortunately, some of the larger lumps so aggregated are themselves curate’s eggs.

A classic example is the so-called MRFIT data. The Multiple Risk Factor Intervention Trial (MRFIT)8 was a massive study mounted in North America, involving screening of either 361,662 or 361,629 men. Data from the MRFIT screenees has contributed very significantly to a number of the meta-analyses.

Werkö from the Swedish Council on Technology Assessment in Health Care has shown clearly that this massive body of data is significantly and seriously flawed.9 There is inconsistency between reports published in different journals simultaneously. The quality control of the basic data is uneven and people using the material seriously have not even bothered to check the relatively simple points investigated by Werkö. Not to do so is a form of scientific laziness, a form of pseudo-science. If these writers have done so and failed to spot the obvious flaws, then their baseline checks have been sloppy. If they have done so, and uncovered the same points as Werkö and chosen to ignore the evidence in front of them, they are true practitioners of pseudo-science and pseudo-medicine.

Meta-analysis has come in for hefty criticism and deservedly so. While its proponents acknowledge that it is a surrogate for the massively expensive prospective studies which are really required, they frequently go way beyond the capacity of the method in terms of the public pronouncements they make. In particular this applies to translation of conclusions relevant to people at special risk, to the advice given to the masses who may not share the same risks or who portray them in only a minor degree. Meta-analysis is now an art form whose scientific significance must be challenged at each stage and with each pronouncement.

Political Involvement

The situation is more sinister than that because politicians through their minions have cottoned on to the value of some of these manipulable analytical techniques. Thus, information gathered in relation to the National Health Service of the United Kingdom is being used to support claims of success of recent government policies. The same types of problem identified by Werkö arise when politicians make use of this type of data. Once politicians and media get into the business of using flawed information, or of distorting sound information for particular purposes, very unhealthy alliances will result.10,11

Our critics are correct in stating that medicine has built a very powerful base within society. Pronouncements by any segment of medicine or its associates are likely to be taken seriously, even in the face of the current wave of mounting scepticism. Epidemiologists and their allies in cardiology have established a major section of the health-disease industry. There are consequences. For instance, an increasing epidemic of osteoporosis in some western countries may well be based upon reduced calcium intake, particularly by women. Dairy products have been the main contributor of calcium in those countries. In contrast to big sections of epidemiology and cardiology, the dairy industry has employed competent nutritionists and made some attempt to keep pace with evolving knowledge of human nutrition. It deserves credit for the burgeoning range of modified milk products, all of which contain calcium. But the damage has been done from within the medical power base. As David Naylor has put it, these difficulties have arisen from the Malthusian growth of uncertainty when multiple technologies combine into clinical strategies and at the public advice level.5

Thoughtful critics of societal development have been drawing attention to these problems. Many advocate a solution through the information revolution, but in terms of the present topic they have failed to perceive that medical information is fragile, patchy and usually imperfect. Like the Lancet editor, I do not believe the consumer watchdog type of approach, with its challenge to the medical powerbase, is going to change the situation at any great speed.11

One healthy fallacy states that the medical powerbase rests solely on possession of scientific information and a monopoly thereof. As I have tried to demonstrate that base is neither secure nor constant. In the health-disease management industry, power does not reside in possession of scientific information. The current success of the inheritors of the old magic, that is the quack acupuncturists, the chelation therapists, many herbalists, naturopaths and so forth, does not reside in a possession of a body of scientific information or a monopoly of its use. This has always been so. Medical power rests as much on uncertainty as it does on technical expertise or possession of a particular body of ephemeral knowledge which will be disproved tomorrow. How can that be so?

The Lancet states it thus, “uncertainty in the face of disease and death fosters a compelling need for patients to trust someone — and a reciprocal authority among doctors. A leap of faith will always be needed. Information does not, and cannot provide all the answers.”11 We thus have a paradox to confront.

Pragmatic Doctors

To return to the aeronautical engineer. Doctors must indeed make decisions, give advice and offer assistance based on limited interpretation of limited evidence. For the foreseeable future doctors must make decisions which will not be derived from carefully controlled prospective randomised clinical trials. They must nevertheless try to make valid decisions. They cannot indulge in the luxury of being inactive in the face of an absence of evidence. That privileged position belongs to the lawyers, the philosophers and the ethicists. In the end doctors have to be pragmatists. Clinical decisions must be made through a plurality of means, each of which must however, undergo “profound interpretative scrutiny”.4

The doctor’s role is more difficult than that of the aircraft wing designer. They must discipline themselves continually to apply medical knowledge in conjunction with their experience and that of their colleagues. “The unifying science of medicine is an inclusive science of interpretation.”4 The black and white situation of 747 wing testing does not occur in medicine. “Medicine is a series of grey zones in which the evidence concerning risk-benefit ratios of competing clinical options is incomplete or contradictory.”5 The grey zones have varying boundaries which change rapidly.

We academics have great difficulty enabling undergraduates and emerging graduates to cope with these phenomena. It is not surprising that many move into pseudo-medicine. It is not surprising that the teaching of orthopaedics is always much more popular with undergraduates than that of clinical medicine. Once again to quote Naylor, “clinical medicine seems to consist of a few things we know, a few things we think we know (but probably don’t) and lots of things we don’t know at all”.5

We academics have to cope with the fact that when evidence alone cannot guide clinical actions, some undergraduates will take up a minimalistic approach whereas others will favour intervention based upon varying balances of inference and experiences and others will turn to pseudo-medicine. Our job as academics is to make emerging clinicians comfortable with a system whereby they can make decisions under conditions of uncertainty.

Over the next decade at least, I believe medical academics will have to confront a somewhat irrational passion for evidence-based medicine and meta-analysis, and we must teach that there are limits to medical evidence and its application. The craft of caring for patients is a legitimate, scientifically appropriate adjunct to medicine. That role is necessary for the comfort and sanity of human society. Osler said, “good clinical medicine will always blend the art of uncertainty with the science of probability.” We need to understand, then to explain what we mean by the term probability.

I shall end with another example. The practice of pseudo-medicine can inflict much discomfort. For instance, young doctors and nurses have considerable difficulty in agreeing to decisions that this patient or that should not be subjected to the indignity of resuscitation procedures, but rather be left to die in peace.

There is a significant and coherent literature indicating that a majority of resuscitation procedures as undertaken in the 1970s and 80s were futile from the outset. The continued pseudo-medical practice in this regard has led to a situation where relatives expect resuscitation procedures to be undertaken. Their concept of power sharing puts heavy pressure on younger doctors to overturn non-resuscitation orders. If the younger doctors submit, an undignified charade ensues. In turn, that situation has created an environment in which aspects of the so-called passive euthanasia debate have become more tangled than was necessary.

I will not dwell further on that point. Rather, I wish to end by emphasising that facing up to uncertainty and accepting areas of ignorance honestly, does not constitute an admission of laziness or incompetence. That, however, is the perspective which sections of the legal profession and society generally are promoting at the present time. If we submit to such pressures and false perspectives we shall end up as we did in relation to the false-confession mistaken-conviction situation, which was discussed at our conference last year.

All professional groups are vulnerable to external influences playing on our own emotional state and anxiety level. Pseudo-medicine thrives in this environment. If we take the subject of evidence in a legal sense we can remind ourselves that a series of techniques have been advised to law authorities over the past century and a number are still in use in the United States, including the polygraph. All have proved to be potentially unreliable, subject to manipulation and all can produce false-positive and false-negative results. If anything their use increases the risk of false confessions.

Those members of the medical and psychology professions whose weakness and pseudo-science has contributed to the situation have much to answer for. Faced with such examples we should have a better understanding of the pervasiveness of the problems of pseudo-medicine and pseudo-science.12 Society needs the NZCSICOP.

Green Peppers

I shall end with the parable of the green peppers. One could term it a parody. The original publication is in the Journal of Irreproducible Results somewhere round about 1955, I think, but I have lost the reference. Some bright workers in Chicago noted that everyone who had eaten green peppers in their youth but had reached the age of 89, had grey hair or white, rotten joints, few teeth, failing eyesight and poor hearing. The main reference in the bibliography was to a guy called Shakespeare somewhere in the early 17th Century. The green pepper eating cohort who had reached the age of 105 were considerably worse off. No-one who had eaten green peppers was alive by the age of 130.

The green pepper industry obviously faltered at that point. However, a subsequent paper which I believe was written but rejected by the same worthy journal, described a restudy of the situation. This showed that people who had eaten green peppers when surveyed at the age of 20 had normal hearing, all their teeth, no lens opacities and sound joints.

In comparison with the older cohorts studied in the first publication, those who had eaten green peppers ten to twenty years earlier showed a mortality rate of 0.05%. Amongst the 90 year old group in the earlier paper, the mortality experienced by that cohort was noted to be 95.2%. Of high significance statistically was the observation that amongst people in that population over the age of 100, only 1% consumed green peppers in the last twenty years. The conclusion was obvious that those who stopped eating green peppers after an interval of twenty years suffered greying and falling of hair, diminished eyesight, reduced hearing, loss of teeth, a very high mortality rate and rotten joints.

Evidence is one thing, quality of evidence another. Intelligent interpretation and carefully planned application of evidence belong to different dimensions. Quality of action based on evidence depends upon the quality of the evidence, its completeness or otherwise, and the quality of the interpretation plus recognition of what is not known and what is not likely to be known over the next years or decades. Life was not meant to be easy.

The practice of medicine combines the twin problems and pleasures inherent in basing action upon adequate evidence on the one hand and inadequate evidence on the other. Practice of the art of medicine is a legitimate activity dependent for its integrity upon the understanding of the dilemmas posed by this dual basis for action and understanding of the nature of science, including the ephemeral nature of scientific knowledge. Pseudo-medicine is practised by those who lack the resolve and energy to face this intellectual challenge.


1) Skrabanek P. Lancet 1993; Vol 342: 1502

2) Margaret Thatcher, PM. BBC World Service interview, 1 Nov 1983

3) Rees J. BMJ; Vol 310: 850-853

4) Horton R. Lancet 1995; Vol 346: 3

5) Naylor ED. Lancet 1995; Vol 345: 840-842

6) Yusuf S et al. Circulation 1993; Vol 87: 2043-2046

7) ISSIS-4 etc. Lancet 1995; Vol 345: 669-685

8) MRFIT. JAMA 1982; Vol 248: 1465-1477

9) Werk[oumlaut] L. J. Int. Med 1995; Vol 237: 507-518

10) Wright M. GP Weekly 1995; 2 August: 12-13

11) Lancet 1995; Vol 345: 1449-1450

12) Lancet 1994; Vol 344: 1447-1450

Alien Ships in Our Skies

One of the perpetrators told the story behind the Grand Interplanetary Hoax of 1952 to the 1994 Skeptics’ Conference.

Hoaxes have probably been a part of life for thousands of years, ranging in scope, intent and outcome. Some such as the Piltdown saga veer out of control and have unforeseen and potentially serious consequences.

When Denis Dutton first asked me to give a paper on the great UFO hoax of 1952, I was somewhat coy about the matter. Subsequently I was tempted to accept, and here we are.

During the early 1900s, mysterious airships were sighted in various parts of the world, and New Zealand was no exception. While various psychological explanations have been forthcoming for the airship episodes, no evidence has surfaced to my knowledge concerning any structured direction to that piece of mystery history, although I have always believed a hoax might have been the initiating event. H.G. Wells’s haunting and sadly prophetic novel The War of the Worlds was available as a textbook to feed the imagination of the susceptible and the gullible.

We need to remember also that the Christian religion has always emphasised the Second Coming. Such teachings reinforce in successive generations the concept that there will be cataclysmic events and visitations, hopefully in one’s own lifetime. The factors which determine the life-cycle of these events are worthy of study. I have no doubt that many of them are the work of pranksters or elaborate hoaxsters, as is the case in the present episode.

Of more interest to people like me in describing something that happened before many readers were born or living in New Zealand is a retrospective analysis of the various participants, the perpetrators, the reactors and the bystanders. In my acceptance letter for this exposure, I said that I would couch my text, “in terms of what this particular episode teaches about young people’s attitude to pomposity in their elders and towards various aspects of the Establishment (in this instance represented by the Otago Daily Times)”.

A serious skeptic must be a serious historian with healthy respect for the broad picture, the fine detail, and also for what Denis has referred to as the partnership between History herself and Lady Luck.

I do not need to stress to this audience the fact that mythology soon surrounds events such as the “Grand Inter-planetary Hoax”, as the Knox College prank is now known in some circles. That mythology is largely concerned both with how the episode arose and with who was involved. I have chosen to tackle this topic in a chronological sequence, introducing analysis of events as I proceed. Such a plan makes it easier to strip away some of the mythology concerning the events of 42 years ago.

Knox College

During the 1950s, Knox College was a male domain occupied by young men from all over New Zealand, of varying ages, studying for a variety of professions. Within the college community were a number of ex-servicemen, most of them studying for the Presbyterian ministry. Knox had not been shaken at that stage by the liberalism of Lloyd Geering, but there were clearly defined groups within the “Div” students, as they were called, ranging from the more fundamentalist to those with what some perceived to be dangerously liberal theological points of view.

Amongst the medical students there was a similar range of believers, with the more traditional rigid group belonging to the Evangelical Union and the more daring, and I would say open-minded, belonging to the Student Christian Movement of which I happened to be President for part of the period we are discussing. At that time the Student Christian Movement quite openly accepted agnostics and others who were exploring and developing their concepts of themselves and the world in general.

Social life in the College centred on the supper parties which moved from room to room. Students became bored with swotting by about 9:00 or 9:30 and gathered together in various rooms and talked until midnight and beyond. The great strength of Knox College lay in those interchanges. These were much richer social gatherings than the somewhat rushed meals in the dining room. I remain very grateful to this phase of my student life, particularly for what I learned from people studying in the other faculties and from the ex-servicemen amongst us.

It needs to be remembered that the early 1950s saw the beginnings of what ultimately resulted in student unrest in a number of other countries and in the revolt of tertiary students against a number of manifestations of the old order. In my opinion, the stirrings began as students realised that a great new order had failed to emerge from the ashes of the Second World War. Rather, a potentially destructive conflict was emerging between what could crudely be called capitalism and Marxism.

Student Idealism

Throughout history, students have been aware of injustice and abuse of power by successive forms of the Establishment. Students have, to some extent, tended to divide themselves into those who put down their heads and acquire a qualification, looking neither to right nor left, versus those who gain pleasure and seek self-fulfilment in genuine attempts to improve, not only their own life, but that of others. While that may be jingoistic and simplistic it is highly relevant to the context.

During 1951 we had endured privation in the Otago winter during the waterfront and the coal miners’ strike. We had shivered in unheated rooms and endured a pretty awful diet amidst a so-called land of plenty. Regardless of the rights or wrongs of the Holland Government’s struggle with the wharfies and the miners, many of us in Otago became increasingly irritated by the sanctimonious attitude of the Otago Daily Times.

This is not mythology; the pompous simperings of the ODT were tackled regularly during capping week. At times the students set out deliberately to antagonise Mr Moffat and his “smug band of journalists and leader writers”. The Star was a ho-hum paper which did not excite nearly as much reaction on the part of the students. Undoubtedly there was much young arrogance behind our own attitudes, but also youthful energy, mixed with mischief and an altruistic outlook.

The idea of launching a major attack on the ODT surfaced in the winter term of 1952. The pre-occupation of the ODT with flying saucers, and the trivialisation of major events which were happening worldwide, was adding fuel to the antagonism felt among a range of students. What I shall term the “idealistic alliance” between many medical, dental, arts and divinity students provided a fertile area for the gestation of the hoax. From the beginning it was critical that a sufficient group of men with the necessary confidence in one another should come together if the venture was to succeed.

According to my records, the hoax idea was mooted vaguely for the first time in late September. Finally a group of five, at one particular supper party, concocted the crucial elements of the enterprise. One of the group had access to a secretary in the Medical School. She was the one significant person from outside the Knox confederacy who participated and maintained her silence over the years.

Final planning, however, was undertaken by a very small group which was a key to the outstanding success of the episode. For many years I kept a copy of the map I used to draw up the original plan. It was very similar to that shown on the construction produced by Brian MacKrell of Palmerston North in 1978.

One document was central to the planning. The illustration confirms that at least some of the things I have said are not mythological. You will note that the single-page document starts off by defining the objective very clearly.

Designed to cure the ODT of Flying Saucerites and inoculate that worthy journal with a healthy degree of septicism [sic].

Spelling mistakes and the unconscious pun based on a spelling mistake, while not Freudian, are nevertheless interesting. We really only had one possibility of getting the typing done, and there was no proof-reading as far as I can recall. For “saucerites” read “sauceritis”, and for “septicism” read “scepticism”.

However, the point of the sentence is quite clear and an educationalist today would applaud the brevity and the irony inherent in that sentence. As you will note, it is a double irony.

The reasoning behind the genesis of two saucers, with different colour codes for the two extra-terrestrial objects, was itself based upon considerable discussion and simplification. There was much complexity during early stages of the planning with a tendency to various forms of hyperbole. All this was strenuously censored for sound reasons.

The blue saucer was to “disappear over the horizon in ever decreasing circles”. We did drag a few coat-tails!

The final paragraphs in the printed document are again an exemplary piece of the hoaxster’s art. Buried within these instructions are the fruits of our own research analysis of reports plus our own rudimentary understanding of the accoutrements of supersonic flight.

Once the document was available, it was distributed throughout the College, through the supper-party networking system. At this point, differing philosophies and personalities within the College became evident in the decisions taken as to who would and who would not take part. Two divinity students, in particular, protested that this was a dishonest exercise with which they could not associate themselves. They believed that the College would be brought into disrepute. Moreover, they were extremely disapproving of other divinity students who were prepared to indulge in such dishonest joviality. They raised a point which was again evident at the 25 year initial revelation. If we were prepared to dissemble to this extent as students, what were we going to be like in later life; what grip would we have on honesty and integrity? Most of us ignored such qualms, and it was notable that a number of ex-servicemen among the divinity students particularly relished their participation.

This was not the only major attack on the ODT by members of Knox College. A famous Resident Fellow, the late Don Anderson, who at one stage was on the staff at Massey University, found the ODT editorial policies particularly irritating and conducted an entirely fictitious correspondence during which he wrote letters for and against bagpipes over a prolonged period. That particular private pillorying of the august journal has never been revealed in public to my knowledge, but I stand to be corrected on that point. As far as I can recall, Don did not take part in this particular exercise but we would not have expected him to do so because he was grossly handicapped and easily identified. As a victim of cerebral palsy, his speech mannerisms were well known in Otago at that time.

There was one major risk involved in the planning which we had to accept. Everything had to be in place so that, as was the custom of those days, we could complete the bulk of our year’s study in the four to six weeks before the final examinations. This was the reason why the briefings and preparations of the instruction sheet occurred early in the third term. Also, various members of the College left at varying times over a total range of about six weeks. In turn the due date of December 6 was determined by the timing of the departure of the last students at the end of their examinations.

This lengthy delay between concluding the planning and the date of execution led to some awkward gaps in coverage of the country and to forgetfulness which I think was genuine on the part of some who had agreed to participate. Russell Cowie made strenuous and ingenious efforts to provide coverage from places in the South Island by preparing additional letters for the relevant areas. Some of the gaps were covered by correspondents stating that they had been travelling by car. This would account for a letter being posted at a distance from the alleged sighting.

To a perceptive reporter who took the trouble to collate the information, the fact that this was a spoof should have been obvious.

Pure Moonshine

One of my favourite pieces was the reporting of the sighting from Hokonui, the home of the famous southern moonshine whisky. The author of that letter had the sense not to sign himself McRae. I still find it incredible that the ODT did not pick up these trailings of the coat.

If I may be excused a modicum of parochialism I shall describe what happened in Auckland. I chose the Herald and rang from a phone box as I came off overtime, on a clear lovely evening. Fortunately the sky was clear over pretty much the whole of New Zealand on the night; this was the first piece of Lady Luck’s benevolence. Had Aotearoa lived up to its name, the whole scheme would have been strangled at birth.

The Herald reporter who received my telephone call was quite bland about it, asked for a name and address which I gave, having carefully selected a street in which the particular number did not exist (in accordance with the plan). I sent in a letter having said I would do so. Obviously no one ever checked up on that, or if they did they kept the observation to themselves.

A colleague from an adjacent wool-store was assigned the Auckland Star. This was a much tougher proposition. He gave a description which tallied with mine, as he walked home from a different wool-store and used a different telephone box. However, the Star reporter wanted a bit more than a name and address and John realised that this was a hazardous moment. However, he had a brilliant idea of saying, “If my wife knew I was out in this street at this time of night there would be all hell”. “No problem sir,” said the Star reporter and swallowed the whole thing hook, line and sinker. Another student used a similar device. Throughout the country people generally had no problems in having their stories accepted.

The Target Bites

The flood of reports obviously raised excitement. As predicted, the ODT gave quite unreasonable prominence to the reports while missing the whole point and not even correlating the North Island and South Island sightings. In its initial reporting it referred to South Island observations only, even though those in the North had been reported in the Northern press, with suitably modest prominence, and on radio.

At no stage did the biggest circulation newspaper of the country, the New Zealand Herald, or the Auckland Star give the story any undue prominence. The attitude of both the Herald and the Star implied that they thought there might be some trickery afoot. The Auckland Star ran a cartoon and a whimsical leader appeared in the New Zealand Herald. I should comment that the New Zealand Herald has always had a whimsical streak to it.

As many of you may know, there is a tradition on April 1 to publish very soberly written articles which are a send-up of this or that, perhaps the most famous one being of the description of the long-lost tunnel under Auckland Harbour excavated for military purposes in the 19th century. Huge numbers of citizens were taken in by that piece of writing. I am not sure whether Ted Reynolds was on the Herald staff in 1952 but the flying saucer leader incorporated the style of writing for which he was later to become notable, if anonymously.

We did have a problem in Auckland. A Canadian Pacific Airliner came over at the critical time and a group of cargo workers sighted something which was not part of our scheme. This was a further piece of intervention by Lady Luck however, because it tended to confuse things in the northern part of the country and it ultimately was quite useful.

Further south much ingenuity was exercised, including a report from one student and his son, (who certainly did not exist at that stage) reporting that they had seen the two discs together. About three days after the event, some newspapers had correlated all the sightings. The Carter Observatory, which had been contacted by more than one newspaper, had officially stated the reports had contained “quite worthwhile information”. The speed of the two objects had been calculated and tallied with our original computations.

“If only I had seen it” sighed Mr W.D. Anderson, a fellow of the Royal Astronomical Society who was consulted by the ODT. “You cannot possibly ignore straightforward, intelligently written reports like these.” He added, “I cannot give explanations off-hand.” Meanwhile, dedicated saucer watchers had concluded that these “fully authenticated reports from New Zealand”, as they were described, indicated that “saucers were flying closer to the Earth’s surface”. This clearly heightened the interest and further raised excitement.

Front Page News

The ODT was in full cry, and 13 days after the event the front or main news page had a double-full-scale column headline entitled “Enigma of the Sky”. It was not the only major reference on the front page during that week. The ODT had commissioned a Mr Anderson and a Mr McGeorge to undertake a survey of the reports. These two worthy gentlemen concluded that:

Assuming that these reports of a swift-moving object in the sky on Saturday night are not the result of collaboration (and they appear to be genuine, independent observations) they constitute a surprising weight of evidence in favour of the proposition that some object of a bluish colour did pass down the South Island.

They went on to calculate size and height of the objects. They ended their report:

We are still looking forward to focusing a telescope on one of these mysterious objects. A telephone call ahead of the object would be helpful, and we suggest that any observer immediately telephone in reports to the nearest office to enable advice to send ahead in time.

A few late reports trickled in and this again was part of the original plan. These were heavily reinforced by Russell Cowie, which ensured that the ODT target was well and truly plastered. He wrote further letters to Southland and Wellington papers to ensure that the coordinated activities of the blue and green discs were recognised.

The excitement eventually died down. The Weekly News of July 12 1953 did feature an article entitled “Mysteries that Fly Past in the Night”, which was based on an interview with Mr H.A. Fulton, president of the Civilian Saucer Interrogation Society of New Zealand (CSINZ). He had been involved early by the ODT and other newspapers at the time of the hoax itself.

The Committee of the CSI had concluded that the most conclusive evidence of the existence of flying saucers was the series of reports received on December 6, 1952. He went on to state that the CSI was satisfied that all the natural and atmospheric explanation by scientists for the appearance of flying saucers did not promise a solution of the riddle.

“Time”, Mr Fulton said, “would tell and the time was not very far away.”

Unexpected Support

Lady Luck favoured us thrice. What we did not know at the time was that we had calculated the speed of our objects such that they would have appeared at the right time over the Gulf of Mexico where a B29 crew saw a small, unidentified flying object. In 1978 the report of that crew still remained on the US Air Force list of unexplained flying objects. The green disc which disappeared off Invercargill could have turned up along a great circle route to the Gulf of Mexico just in time to be observed by the American airmen in their B29. Others have carried out the same correlation which appears in one of the standard books on flying saucers. The New Zealand sighting of 1952 and the B29 report are frequently quoted as being the most convincing evidence to support the reality of UFOs.

In an account prepared in 1984 by Mason Stretch, then Secretary of the Knox College Students’ Club, and presented at an annual meeting of the Knox College Old Boys’ Association, the final two paragraphs ran:

Surely the ODT reporters, the main sub-editors even, must have purred when Mr Thompson of the Carter Observatory said to the ODT, “You have got times and you have got something which might give speeds…that appears to be worthwhile information.”

The ODT had nobly striven to assemble data and report to the public information of world shaking importance — so important indeed that what at other times would be major international news was squeezed out of the headlines by two saucy wee disks [sic] that hissed while hoaxers howled in the background.

I think we were all staggered by the success of the venture and were not quite sure what to do. There was a tacit agreement that nothing should be said. We had achieved our objective, felt satisfied and, quite frankly, the ODT continued on in its ponderous manner. Capping came along next term and, predictably, the memory of the events receded into the background. As I have indicated there were some periodic reports of the 1952 excerpts in the press including the Weekly News article. Some who participated in the hoax did begin to feel a little uneasy that some people 10, 15 and 25 years later were still taking the thing far too seriously, just as the 1909 airship episode with slow moving dirigibles steam-powered from Dargaville to Invercargill towards subsequent sightings in Australia had never been explained. It seemed reasonable to leave things for a while, but not forever.

In the Christchurch Press of 4 March 1978, Brian MacKrell of Palmerston North published an article headlined “The Night of the Hissing Discs”. He had earlier analysed the 1952 newspaper reports and his work produced the map referred to earlier. He said he was not a member of any organisation which believed in UFOs but he had collected newspaper reports of the sightings as a child. He had linked up the B29 bomber report from the Gulf of Mexico. He was aware of the 1909 airship reports.

With what appears to have been unconscious irony, the ODT republished the MacKrell article one week later. There is no indication that the ODT had any inkling of its role as the prime target in 1952.

Some of the group of now moderately old Knox men decided enough was enough, and Ken Nichol of Christchurch Teachers’ College revealed to the Press a general outline of the hoax. As far as I can tell the ODT never published Ken’s article.

As we expected, the reaction to the Ken Nichol revelation was mixed. Some letters refused to accept that the hoax was a hoax.

I believe it is clear from the editorial in the New Zealand Herald and the cartoon in the Auckland Star that the northern papers regarded the whole affair as entertaining and amusing. I suspect in retrospect that they might even have guessed that the ODT was the target. Certainly, when one looks at the New Zealand Herald over the relevant time, international news was not displaced off the front page in the Auckland papers as it was in the Otago Daily Times.

In terms of its basic purpose, the hoax was designed to make the ODT look foolish, mainly in the eyes of those who perpetrated the hoax itself, and hopefully to others. The low standard of professionalism shown by the newspaper reporters and sub-editors in terms of their analysis of Press Association reports, their failure to undertake some simple correlations, and their failure to pick-up the clues deliberately pointing to this being a hoax, almost certainly had no impact within the paper itself and probably not amongst a majority of worthy readers in Otago.

Hoaxers Satisfied

To those of us who took part in the hoax, there was a buzz of excitement and gratification. Our suspicion that the Fourth Estate could be manipulated, even by amateurs, was confirmed as were our thoughts concerning what determined some major aspect of newspaper policy. In a city that had prided itself as the intellectual centre of the country, the toes and part of the fore-foot of the main newspaper were revealed to us as objects of clay.

While we were poking fun at one major pillar of the Otago establishment, we were also indulging in the freedom offered by that academic environment and by New Zealand generally. Like the Oxford students who dug up part of Oxford or Regent Street and got away with it for something like a week, we had risked creating a nuisance of ourselves at the same time as we had challenged pomposity and credulity. We were mounting what we believed to be a humorous but constructive protest against what we correctly perceived to be the destructive nature of modern day superstition and witchcraft, and their handmaidens in some sections of the media.

Ours was a one-off exercise unlike the much more elaborate campaign undertaken in the seventies and eighties by the crop circle hoaxers. Bower and Chorley were in their fifties when they concocted their crop circle hoax as a joke, once again based upon a flying saucer motive. They also were staggered at their success and instead of confessing to newspapers, they made use of the original scheme to spell out the words “we are not alone” in 1986, and “copycats” in 1990. Once again, however, the believers took over and the huge geometrical precision of the July 1990 hoax convinced UFO Research Groups and the United Believers in Intelligence, that intelligence beyond any earthbound being had created the nine circle Worcestershire patterns.

Those particular episodes are much more complex than our own efforts, and just who is hoaxing whom remains unclear. At times it seems clear that the crop circle series may even have been maintained in the interest of some journalists, cynical or otherwise.

History does repeat itself in the arena of hoaxism and Lady Luck rides side-saddle e’en to the noo.

At least some who reacted to Ken Nichol’s preliminary confession believed that the Knox College students had betrayed their academic standards and had displayed a shocking lack of integrity. How could we be trusted on any stage thereafter? The argument that young radicals later became conservatives did not hold much weight with these stern critics. I believe that such guardians of absolute truth failed to perceive that we were acting out of a very healthy intellectual approach to life in general.

Moreover, from what I know of the subsequent lives of a moderately large number of the group concerned, they have maintained a sense of proportion during their careers and they have neither become cynics nor carping critics. Maybe it is their sense of humour combined with their serious intent and a critical capacity to analyse complex issues which has maintained in them this balanced perspective which is a key element in professional success.

I feel there is ironic justice perceptible in the fact that Russell Cowie is an acknowledged expert in the area of the nature and use of historical evidence. I hope that young people continue to behave in the way we did, particularly if they maintain into later adult life a sense of fun, a sense of proportion and an approach to the Establishment which is responsible on the one hand, but skeptical and critical on the other.

And so I conclude and leave you to your own interpretations of one of the cataclysmic events which brought to an end anno domini 1952.