Tag: medicine

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.

Uncertainty

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.

Nihilism

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.

Anti-orthodoxy

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.

References

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