Dr. Steven Novella eats, sleeps, and breathes science. An academic clinical neurologist by day at the Yale University of Medicine, he spends much of the rest of his time promoting science and rationality through the massively popular weekly podcast he hosts, The Skeptics Guide to the Universe, his own blog, Neurologica, and the influential blog he founded, Science-Based Medicine. He is also the President and co-founder of the New England Skeptical Society. Our conversation revealed how every question is complicated, and the subtle link between seemingly unrelated pseudo-sciences like intelligent design and alternative medicine.
Keith Daniels: A lot of the claims that you deal with, in terms of pseudoscience -- things like anti-vaccination, have to do with problems that medical science hasnt figured out yet. You dont see a lot of people trying to do alternative medicine for things that already have scientific cures. Do you think a lot of these things will go away as science cures whatever-it-was?
Dr. Steven Novella: Well, Id like to think so. There certainly is that relationship where, the more mysterious the disease is, the less effective our evidence-based treatments, the more that gap of knowledge is filled with superstition, pseudo-science, or alternatives. I do think to some extent theyll be squeezed out, but there are, unfortunately, institutions now dedicated to things like homeopathy, or acupuncture, or chiropractic, et cetera. That develops a certain cultural momentum or inertia, so these things are not going to just go away because their reasons for existing go away. I think they will find a niche. They might just migrate over to other things, or reinvent themselves in some other way, but I doubt they will just go quietly into the night.
KD: Because the money is so good.
SN: Absolutely! Theres a huge financial incentive not to give up what theyre doing. Theyre not science-based to begin with, so science is not going to dissuade them in any way.
KD: When you see somebody make millions of dollars off some shit like putting in foil in a bracelet and selling it, do you ever wonder if youre in the wrong line of work?
SN: [Laughs] Definitely my colleagues and I will joke about that, the fact that were on the wrong side of this equation. Were certainly not making any money doing what were doing. Were often going up against people who are extremely well funded, because theres a lot of money on the other side. Theres a lot of money in fraud, or in selling hope -- whether its false hope or not -- and theres no money in skepticism. Were evidence of that.
KD: How careful do you have to be when youre debunking or taking down a bogus medical claim just because of the seriousness of the concern behind it? For example, if you tell people there are no ghosts they probably wont get their feelings hurt, but if you tell them that homeopathys not going to cure their cancer...
SN: Yeah, it is very difficult to go after beliefs when there is something very real and serious on the line. With ghosts... people actually do get quite upset when you address their core beliefs. Whatever beliefs they have, nobody likes to be told that something they believe is wrong, but when there is something really tangible on the line, like health, then it brings a new dimension into it. Plus, Im a physician, so I have to be somewhat in that role when Im dealing with these issues. I rarely will confront an actual individual person who is claiming that something cured their own disease, or cancer, or whatever it is. I usually like to talk about the evidence and the claims more in the abstract. Of course, if my own patient asked me for information, then Im happy to give it to them, but I cant treat somebody whos not my patient as if they were by giving them advice; thats not appropriate. I also think its just really tricky and not very effective, and also questionable ethically to directly address somebodys personal beliefs or claims about their own experience. Id much rather deal with the questions on the level of what the scientific evidence says.
KD: What do you think are some of the more common mistakes scientists make when dealing with the media?
SN: Theres definitely a skill-set involved in dealing with the media. Scientists may understand their field very well, but if they dont understand the nature of science journalism they can get into trouble. Often I feel that scientists will be goaded into making very irresponsible statements; statements that make the research that theyre talking about sound a little bit more exciting or interesting, but they dont realize that theyre also playing into fear-mongering or a distortion of the evidence. They may not be aware of the fact that journalists are often just fishing for quotes that theyre going to plug into the story theyve basically already written. So, as a scientist dealing with the media, you cant just answer questions straight up. You have to talk to the journalist, or whoever it is that youre dealing with, and make sure that they understand what the real story is, get a feel of where theyre coming from. Also, you need to talk in self-contained soundbites that will stand on their own, that cant be easily taken out of context or twisted. Those are the core things that a scientist needs to know when dealing with journalists. Of course, I read stories all the time where scientists are made to look like fools, and you never know how they were treated by the journalist. Did they really say something that stupid? Or were they just naive and being taken out of context?
KD: Do you think that media literacy ought to be included in the training in a science education?
SN: Well, it should at least be optional. I think the resources should be there. Not every scientist needs to deal with the media, or develop that skill-set. You either do need to be aware that there is a skill-set, or at least make an effort in becoming competent in dealing with the media; or, you should leave it to your colleagues to do so. You shouldnt just naively go, OK, Ill do a press-conference, or, Ill talk about my research, without having any idea what youre doing; thats where scientists get into deep trouble.
KD: One of the logical fallacies that youve cautioned against often on The Skeptics Guide to the Universe is argument from authority, but how does someone like me who works all the time, is not a scientist, know who to trust?
SN: Yeah, thats tricky, and its getting trickier. Theres no easy answer to that. Ill explain part of the problem. There are a lot of false authorities out there. There are professions that are not based upon science, evidence, and reason, but they might be licensed and have the imprimatur of legitimacy, and certainly the public can get fooled into thinking that theyre a reliable source of information. There are institutions that are created specifically to promote an ideology, but try to make themselves look as if they are a legitimate scientific organization. There are groups that do that specifically to confuse the public and to muddy the waters. There are also just people who are grossly misinformed, but can set themselves up as some kind of authority on the internet. Its easy to have a slick enough website that you can appear to have legitimacy. So theres a lot of minefields out there of information. I see this all the time, where people are just confused by the misinformation, and theyre not sure which authorities to trust. Again, this is another skill-set that I think the public needs to develop in the age of the internet and this proliferation of information: you need to have some idea of how to navigate all of these various sources of varying authority. I think [there are] a couple of good rules-of-thumb to follow: one is to try to figure out what the consensus is. Dont ever trust a single source. Try to look at multiple sources and see if theres a consensus of opinion that emerges. Any one opinion could be idiosyncratic or quirky, and theres no reason to rely on any single opinion. Also, there are still brick-and-mortar institutions that are well-established; universities, for example. They will tend to be more trustworthy than some fly-by-night website. Also, always find what the other side is saying. Whenever I get an opinion on a topic, I want to find what the people who dont believe that opinion are saying. Until you specifically look for the other side you shouldnt think that you have the complete story. Usually, youll see an asymmetry: the more reliable sources -- the recognized professional organizations, the institutions and universities -- tend to coalesce around a certain consensus, and then theres either a minority or an ideological opinion that is on the outside. You also get a flavor for the kind of opinions that are more likely to be more like a straightforward, scientific opinion, versus an ideological one. [If] people are starting to talk about conspiracy theories and [how] their views are being suppressed, then that should be a red flag that maybe theyre just trying to justify why their opinions are not accepted by the scientific community, and generally thats just an excuse for beliefs that are not based upon science. Theres a lot more, but those are the kind of skills and the rules-of-thumb that you can develop to at least try to rely upon more reliable sources.
KD: How influential has the Science-Based Medicine site that you helped found become? Are you starting to see it expand beyond the skeptic community and into the medical community?
SN: Yeah, its definitely starting to be fairly prominent. We still have a ways to go, I think, in terms of developing it, but Ill notice, for example, when Im searching for a topic, or a question that I have, a Science-Based Medicine article will often come up on the first page [of the search results], often the first hit, and I wasnt searching on a skeptical topic or specifically on Science-Based Medicine. Its nice to see that its coming up very high just on searches for general medical information. Thats a good indication that there are a lot of people linking to it and using it as a resource. I think, just as an internet resource, its doing quite well. I think the area where we have a lot of work to do is developing it into more of an academic resource, and achieving some of the trappings of academic legitimacy. For example, were trying to retool some of our more basic concepts into peer-reviewed articles to get published on other sites, rather than publishing everything on our own site.
KD: A controversial video-game came out last week, Bulletstorm. Fox News rolled out some scientist who said this was going to increase rapes. What, if any, evidence is there that video-games harm people in any way?
SN: The literature on video-games is a little mixed. If someone has a predisposition to violence, engaging in violent video-game play certainly may increase their aggressiveness; theres evidence to support that notion. There isnt really a lot of evidence to support that theres actual negative societal consequences to it, that people will actually go out there and commit crimes because they were egged on by video-games. So, it depends on what kind of research you look at. Yes, it might increase aggressiveness. I believe there was a study that showed that certain kinds of video-games at least correlate with increased promiscuity. Part of the problem with a lot of this research is its all correlational, so you can always ask the question, Do video-games make kids aggressive, or, do aggressive kids like these kinds of video-games? When you control for that sort of thing, any remaining effect is actually fairly weak. I dont think its a big societal problem is the bottom line, that we have to put a lot of time and energy into dealing with the effect of video-games.
KD: Do you feel that marijuana and other recreational drugs should be legalized?
SN: Thats a thorny question. I have mixed feelings about that. Its really tricky. As a neurologist, I know that the brain certainly responds physiologically to certain addictive substances. They are addictive. They actually change brain chemistry. To that extent, they take away peoples free will and ability to really control their actions, and they can take over peoples lives. Its a susceptibility in our biology, in our brains, so thats, I think, clearly established by science; thats how the science informs this question. But then where do we go from there? Do we err on the side of individual freedom? Do people get to decide what to do to themselves and to their own bodies? I can certainly understand that point of view, but people may get into substances not being fully aware of the power of addiction: the fact that theyre actually going to lose themselves in a very real and important way to these substances. Does society have a right to protect them from themselves? There is also, if you look at the societal harm from use of recreational drugs it gets a little tricky, because again you get into the correlation versus causation thing. The greatest societal harm is caused by alcohol, which is the one legal recreational drug. By far, alcohol is the worst thats out there. You can ask, Is that because its legal? Is that why its worse, or is there something else about alcohol that makes it so bad? Or is it just that, culturally, because its so widespread? You can try to compare countries that legalized certain drugs to those who dont, [but] the comparisons are very problematic. The other aspect of this is just the practical aspects that the war on drugs is just not very effective. It just creates more crime and drives it underground, and takes away the ability to control it all. In the end, you have a lot of conflicting information, and conflicting ethical choices. I dont personally think theres one objective answer. It really depends on your value judgements. For me, its a real dilemma. Its a real vulnerability in our biology. We have to learn how to minimize the negative effects of this, and theres no one objective, correct answer.
KD: Speaking of thorny issues: how do you feel about socialized medicine? Do you think that health-care is something everyone has a right to, regardless of their ability to pay?
SN: Well, the short answer is, Yes. Health-care ethics are certainly based upon the idea that everybody has a right to at least basic health-care. We certainly dont turn away people who need urgent care because of their inability to pay. So, thats one issue. From an ethical point of view, as a profession, we cant turn away or deny basic care, but once you get beyond that, again, it gets really tricky. How do you define basic care? Where do you draw the line? Different states, different countries, draw the line in different places. Is an organ transplant at the cost of hundreds of thousands of dollars considered basic care, or is that extraordinary care? Is that heroic care? And whats the difference? Also, we find ourselves now in somewhat of a zero-sum game in that we have finite health-care resources. Were exceeding, really, our ability to deliver those resources, and so, when you give somebody a liver transplant, youre also taking away resources that could go to a hundred children. So its not just that that person has a right to a liver transplant, its, Whats greater? The right of that one person to a liver transplant, or the rights of a hundred children to basic health-care? These are tricky issues that are not being dealt with head-on by the political system. I think they did a good job of avoiding the really important issues during the debate. I think everyone is pretty much in favor of the notion of universal coverage, just because theres really no downside to it, in that its efficient. Its massively inefficient to have uninsured people who then use the emergency room as their primary care system. Just for efficiency, which we absolutely need to do because of the costs of health-care. We need to have a system in place where everybody can get preventive care and basic care, and efficient care. It also absolutely appeals to everyones sense of social justice. I dont think anybody thinks that people should be turned away [from] health-care. The really hard question is, How do we devise a system to pay for it all? Thats where you get to the point where, again, I dont think theres one correct answer. Every system has perverse incentives in it of one type or another. Whoevers paying for it has a huge disincentive to pay for it. If anyone's reimbursement, the money that they make, is at all tied to the amount of health-care that they deliver, then they have an incentive to deliver more health-care. If you then flip it and give them an incentive not to treat, then they have an incentive not to treat. Wed like there to be an incentive-free system where practitioners and patients are only motivated to do whats best without worrying about their bottom line. Actually, I sort of practice in that situation myself. As an academic, Im salaried, I dont get a fee for service; I dont get paid based on my volume. Thats kind of nice, but the system does still care. The system that I work in does have to be solvent, or at least organize itself in such a way that its not losing too much money. So, you can rearrange the furniture on the deck of the Titanic, as they say, but its not really changing the overall cost of the system. Whether youre paying it through taxes, or premiums, or higher costs of goods, were all ultimately paying for health-care in the end anyway. So, I think we should just think about how to make the system maximally efficient, fair, and free of perverse incentives. But theres no one perfect system, you just have to sort of pick your poison.
KD: Have you been following the Planned Parenthood funding issue? Is that something that concerns you?
SN: Ive been following that issue in general. I sort of have this vague sense that theres been some activity on that issue recently, but I havent had a chance to get up to date on it. Is there something specific?
KD: The Republicans in the House of Representatives, but not the Senate, have voted to remove funding for it. I assume that this has to do with trying to limit abortion, but it seems sort of... short-sighted?
SN: Yeah. That definitely is about the abortion issue, theres no question. Abortion is such an emotional issue. Its one of those political issues that sort of poisons everything it touches, and so you have a lot of innocent bystanders, like providing preventative or primary care to women. Reproductive care to women gets sacrificed to this ideological issue of abortion, and the government funding abortion. Unfortunately, again, people have sort of focused on the more ideological questions, and the more practical issues get lost in the shuffle.
KD: What do you think is the most dangerous of the prevailing alternative medicine claims out there right now? Anti-vaccination? Homeopathy?
SN: Its really hard to quantify. There are a number that certainly deserve to be mentioned. You bring up anti-vaccinationists. I think that their specific claims are very dangerous. Theyre trying to convince people not to get vaccinated. Its only the safest and most effective public-health measure invented by man, and they are trying to convince people that it is, in fact, dangerous and not effective. [They are] just full of misinformation, and that is leading to previously preventable diseases coming back. I mean, people are actually dying. Kids are dying from preventable diseases because their parents wont vaccinate them, because theyve been made to be afraid by this misinformation. But the scope of it is still on the small side. Thats where it gets hard to compare. Homeopathy is not that big in the United States; I think its a much bigger problem in Europe. Chiropractic is a much bigger phenomenon in the United States, and I think that it sucks a lot of resources away from medicine, and can serve to delay definitive medical diagnostic information. To a small degree, theres some direct harm. To a lot of these things, the direct harm issue is actually pretty minor. Its more the indirect things: the diversion of resources, the delay of diagnosis or care. I think the big problem is just that the marketing campaign of the alternative-medicine proponents has been so successful over the last twenty years that theyve successfully profoundly confused the public on a lot of fundamental issues, and theyre doing a lot of harm to the practice of science-based medicine, to the education of the next generation of physicians. Things like confusing natural with safe and effective, or holistic with patient-centered, actually trying to weave these really confused and tangled arguments about the nature of science, and the relationship between science and the practice of medicine. This is all having a very insidious and negative effect on the institution of medicine and the beliefs of the public about how medicine works, and how science works. Its very hard to quantify all of that, but I definitely see it as having a tremendous negative effect. I see patients every day struggling with all of this marketing misinformation: wasting money, wasting time, subjecting themselves to needless risk, because its just in the culture now, Yes, I want a natural alternative. Meanwhile, theyre taking something which is basically an unregulated, unpurified drug with unknown content and unknown side-effects and unknown drug-interactions, and theyre spending their limited health-care dollars on this rather than on a proven treatment because theyve bought into the marketing hype. They often have no clue what it is theyre really buying. Its unfortunate that theyve been so successful in pulling off the swindle of the century, really, and in convincing so many people that their marketing con is somehow an acceptable alternative to logic and evidence.
KD: It seems like thats happening on all fronts. Little kids get it at school with intelligent design. Then we get the climate change debate. And then its in medicine, too. It just seems like people are being taught that theres a false balance, that, theres always two sides to everything.
SN: Yeah. In many ways, I think theyre sort of learning off of each other. It is again, this sort of marketing culture that has learned how to market pseudo-science, whether its intelligent design, or alternative medicine, or global warming denial, or whatever it is. I see a remarkable consistency in the kinds of arguments that are being used by all these otherwise very different endeavors. Theyre all ultimately a way of promoting an ideology, or promoting a financial interest, against the scientific consensus, and their methods are remarkably similar. Theyre largely selling misinformation, doubt, confusion, and some fairly sophisticated but ultimately anti-scientific arguments in order to undercut the bottom-line that what theyre selling is not consistent with the science.
Keith Daniels: A lot of the claims that you deal with, in terms of pseudoscience -- things like anti-vaccination, have to do with problems that medical science hasnt figured out yet. You dont see a lot of people trying to do alternative medicine for things that already have scientific cures. Do you think a lot of these things will go away as science cures whatever-it-was?
Dr. Steven Novella: Well, Id like to think so. There certainly is that relationship where, the more mysterious the disease is, the less effective our evidence-based treatments, the more that gap of knowledge is filled with superstition, pseudo-science, or alternatives. I do think to some extent theyll be squeezed out, but there are, unfortunately, institutions now dedicated to things like homeopathy, or acupuncture, or chiropractic, et cetera. That develops a certain cultural momentum or inertia, so these things are not going to just go away because their reasons for existing go away. I think they will find a niche. They might just migrate over to other things, or reinvent themselves in some other way, but I doubt they will just go quietly into the night.
KD: Because the money is so good.
SN: Absolutely! Theres a huge financial incentive not to give up what theyre doing. Theyre not science-based to begin with, so science is not going to dissuade them in any way.
KD: When you see somebody make millions of dollars off some shit like putting in foil in a bracelet and selling it, do you ever wonder if youre in the wrong line of work?
SN: [Laughs] Definitely my colleagues and I will joke about that, the fact that were on the wrong side of this equation. Were certainly not making any money doing what were doing. Were often going up against people who are extremely well funded, because theres a lot of money on the other side. Theres a lot of money in fraud, or in selling hope -- whether its false hope or not -- and theres no money in skepticism. Were evidence of that.
KD: How careful do you have to be when youre debunking or taking down a bogus medical claim just because of the seriousness of the concern behind it? For example, if you tell people there are no ghosts they probably wont get their feelings hurt, but if you tell them that homeopathys not going to cure their cancer...
SN: Yeah, it is very difficult to go after beliefs when there is something very real and serious on the line. With ghosts... people actually do get quite upset when you address their core beliefs. Whatever beliefs they have, nobody likes to be told that something they believe is wrong, but when there is something really tangible on the line, like health, then it brings a new dimension into it. Plus, Im a physician, so I have to be somewhat in that role when Im dealing with these issues. I rarely will confront an actual individual person who is claiming that something cured their own disease, or cancer, or whatever it is. I usually like to talk about the evidence and the claims more in the abstract. Of course, if my own patient asked me for information, then Im happy to give it to them, but I cant treat somebody whos not my patient as if they were by giving them advice; thats not appropriate. I also think its just really tricky and not very effective, and also questionable ethically to directly address somebodys personal beliefs or claims about their own experience. Id much rather deal with the questions on the level of what the scientific evidence says.
KD: What do you think are some of the more common mistakes scientists make when dealing with the media?
SN: Theres definitely a skill-set involved in dealing with the media. Scientists may understand their field very well, but if they dont understand the nature of science journalism they can get into trouble. Often I feel that scientists will be goaded into making very irresponsible statements; statements that make the research that theyre talking about sound a little bit more exciting or interesting, but they dont realize that theyre also playing into fear-mongering or a distortion of the evidence. They may not be aware of the fact that journalists are often just fishing for quotes that theyre going to plug into the story theyve basically already written. So, as a scientist dealing with the media, you cant just answer questions straight up. You have to talk to the journalist, or whoever it is that youre dealing with, and make sure that they understand what the real story is, get a feel of where theyre coming from. Also, you need to talk in self-contained soundbites that will stand on their own, that cant be easily taken out of context or twisted. Those are the core things that a scientist needs to know when dealing with journalists. Of course, I read stories all the time where scientists are made to look like fools, and you never know how they were treated by the journalist. Did they really say something that stupid? Or were they just naive and being taken out of context?
KD: Do you think that media literacy ought to be included in the training in a science education?
SN: Well, it should at least be optional. I think the resources should be there. Not every scientist needs to deal with the media, or develop that skill-set. You either do need to be aware that there is a skill-set, or at least make an effort in becoming competent in dealing with the media; or, you should leave it to your colleagues to do so. You shouldnt just naively go, OK, Ill do a press-conference, or, Ill talk about my research, without having any idea what youre doing; thats where scientists get into deep trouble.
KD: One of the logical fallacies that youve cautioned against often on The Skeptics Guide to the Universe is argument from authority, but how does someone like me who works all the time, is not a scientist, know who to trust?
SN: Yeah, thats tricky, and its getting trickier. Theres no easy answer to that. Ill explain part of the problem. There are a lot of false authorities out there. There are professions that are not based upon science, evidence, and reason, but they might be licensed and have the imprimatur of legitimacy, and certainly the public can get fooled into thinking that theyre a reliable source of information. There are institutions that are created specifically to promote an ideology, but try to make themselves look as if they are a legitimate scientific organization. There are groups that do that specifically to confuse the public and to muddy the waters. There are also just people who are grossly misinformed, but can set themselves up as some kind of authority on the internet. Its easy to have a slick enough website that you can appear to have legitimacy. So theres a lot of minefields out there of information. I see this all the time, where people are just confused by the misinformation, and theyre not sure which authorities to trust. Again, this is another skill-set that I think the public needs to develop in the age of the internet and this proliferation of information: you need to have some idea of how to navigate all of these various sources of varying authority. I think [there are] a couple of good rules-of-thumb to follow: one is to try to figure out what the consensus is. Dont ever trust a single source. Try to look at multiple sources and see if theres a consensus of opinion that emerges. Any one opinion could be idiosyncratic or quirky, and theres no reason to rely on any single opinion. Also, there are still brick-and-mortar institutions that are well-established; universities, for example. They will tend to be more trustworthy than some fly-by-night website. Also, always find what the other side is saying. Whenever I get an opinion on a topic, I want to find what the people who dont believe that opinion are saying. Until you specifically look for the other side you shouldnt think that you have the complete story. Usually, youll see an asymmetry: the more reliable sources -- the recognized professional organizations, the institutions and universities -- tend to coalesce around a certain consensus, and then theres either a minority or an ideological opinion that is on the outside. You also get a flavor for the kind of opinions that are more likely to be more like a straightforward, scientific opinion, versus an ideological one. [If] people are starting to talk about conspiracy theories and [how] their views are being suppressed, then that should be a red flag that maybe theyre just trying to justify why their opinions are not accepted by the scientific community, and generally thats just an excuse for beliefs that are not based upon science. Theres a lot more, but those are the kind of skills and the rules-of-thumb that you can develop to at least try to rely upon more reliable sources.
KD: How influential has the Science-Based Medicine site that you helped found become? Are you starting to see it expand beyond the skeptic community and into the medical community?
SN: Yeah, its definitely starting to be fairly prominent. We still have a ways to go, I think, in terms of developing it, but Ill notice, for example, when Im searching for a topic, or a question that I have, a Science-Based Medicine article will often come up on the first page [of the search results], often the first hit, and I wasnt searching on a skeptical topic or specifically on Science-Based Medicine. Its nice to see that its coming up very high just on searches for general medical information. Thats a good indication that there are a lot of people linking to it and using it as a resource. I think, just as an internet resource, its doing quite well. I think the area where we have a lot of work to do is developing it into more of an academic resource, and achieving some of the trappings of academic legitimacy. For example, were trying to retool some of our more basic concepts into peer-reviewed articles to get published on other sites, rather than publishing everything on our own site.
KD: A controversial video-game came out last week, Bulletstorm. Fox News rolled out some scientist who said this was going to increase rapes. What, if any, evidence is there that video-games harm people in any way?
SN: The literature on video-games is a little mixed. If someone has a predisposition to violence, engaging in violent video-game play certainly may increase their aggressiveness; theres evidence to support that notion. There isnt really a lot of evidence to support that theres actual negative societal consequences to it, that people will actually go out there and commit crimes because they were egged on by video-games. So, it depends on what kind of research you look at. Yes, it might increase aggressiveness. I believe there was a study that showed that certain kinds of video-games at least correlate with increased promiscuity. Part of the problem with a lot of this research is its all correlational, so you can always ask the question, Do video-games make kids aggressive, or, do aggressive kids like these kinds of video-games? When you control for that sort of thing, any remaining effect is actually fairly weak. I dont think its a big societal problem is the bottom line, that we have to put a lot of time and energy into dealing with the effect of video-games.
KD: Do you feel that marijuana and other recreational drugs should be legalized?
SN: Thats a thorny question. I have mixed feelings about that. Its really tricky. As a neurologist, I know that the brain certainly responds physiologically to certain addictive substances. They are addictive. They actually change brain chemistry. To that extent, they take away peoples free will and ability to really control their actions, and they can take over peoples lives. Its a susceptibility in our biology, in our brains, so thats, I think, clearly established by science; thats how the science informs this question. But then where do we go from there? Do we err on the side of individual freedom? Do people get to decide what to do to themselves and to their own bodies? I can certainly understand that point of view, but people may get into substances not being fully aware of the power of addiction: the fact that theyre actually going to lose themselves in a very real and important way to these substances. Does society have a right to protect them from themselves? There is also, if you look at the societal harm from use of recreational drugs it gets a little tricky, because again you get into the correlation versus causation thing. The greatest societal harm is caused by alcohol, which is the one legal recreational drug. By far, alcohol is the worst thats out there. You can ask, Is that because its legal? Is that why its worse, or is there something else about alcohol that makes it so bad? Or is it just that, culturally, because its so widespread? You can try to compare countries that legalized certain drugs to those who dont, [but] the comparisons are very problematic. The other aspect of this is just the practical aspects that the war on drugs is just not very effective. It just creates more crime and drives it underground, and takes away the ability to control it all. In the end, you have a lot of conflicting information, and conflicting ethical choices. I dont personally think theres one objective answer. It really depends on your value judgements. For me, its a real dilemma. Its a real vulnerability in our biology. We have to learn how to minimize the negative effects of this, and theres no one objective, correct answer.
KD: Speaking of thorny issues: how do you feel about socialized medicine? Do you think that health-care is something everyone has a right to, regardless of their ability to pay?
SN: Well, the short answer is, Yes. Health-care ethics are certainly based upon the idea that everybody has a right to at least basic health-care. We certainly dont turn away people who need urgent care because of their inability to pay. So, thats one issue. From an ethical point of view, as a profession, we cant turn away or deny basic care, but once you get beyond that, again, it gets really tricky. How do you define basic care? Where do you draw the line? Different states, different countries, draw the line in different places. Is an organ transplant at the cost of hundreds of thousands of dollars considered basic care, or is that extraordinary care? Is that heroic care? And whats the difference? Also, we find ourselves now in somewhat of a zero-sum game in that we have finite health-care resources. Were exceeding, really, our ability to deliver those resources, and so, when you give somebody a liver transplant, youre also taking away resources that could go to a hundred children. So its not just that that person has a right to a liver transplant, its, Whats greater? The right of that one person to a liver transplant, or the rights of a hundred children to basic health-care? These are tricky issues that are not being dealt with head-on by the political system. I think they did a good job of avoiding the really important issues during the debate. I think everyone is pretty much in favor of the notion of universal coverage, just because theres really no downside to it, in that its efficient. Its massively inefficient to have uninsured people who then use the emergency room as their primary care system. Just for efficiency, which we absolutely need to do because of the costs of health-care. We need to have a system in place where everybody can get preventive care and basic care, and efficient care. It also absolutely appeals to everyones sense of social justice. I dont think anybody thinks that people should be turned away [from] health-care. The really hard question is, How do we devise a system to pay for it all? Thats where you get to the point where, again, I dont think theres one correct answer. Every system has perverse incentives in it of one type or another. Whoevers paying for it has a huge disincentive to pay for it. If anyone's reimbursement, the money that they make, is at all tied to the amount of health-care that they deliver, then they have an incentive to deliver more health-care. If you then flip it and give them an incentive not to treat, then they have an incentive not to treat. Wed like there to be an incentive-free system where practitioners and patients are only motivated to do whats best without worrying about their bottom line. Actually, I sort of practice in that situation myself. As an academic, Im salaried, I dont get a fee for service; I dont get paid based on my volume. Thats kind of nice, but the system does still care. The system that I work in does have to be solvent, or at least organize itself in such a way that its not losing too much money. So, you can rearrange the furniture on the deck of the Titanic, as they say, but its not really changing the overall cost of the system. Whether youre paying it through taxes, or premiums, or higher costs of goods, were all ultimately paying for health-care in the end anyway. So, I think we should just think about how to make the system maximally efficient, fair, and free of perverse incentives. But theres no one perfect system, you just have to sort of pick your poison.
KD: Have you been following the Planned Parenthood funding issue? Is that something that concerns you?
SN: Ive been following that issue in general. I sort of have this vague sense that theres been some activity on that issue recently, but I havent had a chance to get up to date on it. Is there something specific?
KD: The Republicans in the House of Representatives, but not the Senate, have voted to remove funding for it. I assume that this has to do with trying to limit abortion, but it seems sort of... short-sighted?
SN: Yeah. That definitely is about the abortion issue, theres no question. Abortion is such an emotional issue. Its one of those political issues that sort of poisons everything it touches, and so you have a lot of innocent bystanders, like providing preventative or primary care to women. Reproductive care to women gets sacrificed to this ideological issue of abortion, and the government funding abortion. Unfortunately, again, people have sort of focused on the more ideological questions, and the more practical issues get lost in the shuffle.
KD: What do you think is the most dangerous of the prevailing alternative medicine claims out there right now? Anti-vaccination? Homeopathy?
SN: Its really hard to quantify. There are a number that certainly deserve to be mentioned. You bring up anti-vaccinationists. I think that their specific claims are very dangerous. Theyre trying to convince people not to get vaccinated. Its only the safest and most effective public-health measure invented by man, and they are trying to convince people that it is, in fact, dangerous and not effective. [They are] just full of misinformation, and that is leading to previously preventable diseases coming back. I mean, people are actually dying. Kids are dying from preventable diseases because their parents wont vaccinate them, because theyve been made to be afraid by this misinformation. But the scope of it is still on the small side. Thats where it gets hard to compare. Homeopathy is not that big in the United States; I think its a much bigger problem in Europe. Chiropractic is a much bigger phenomenon in the United States, and I think that it sucks a lot of resources away from medicine, and can serve to delay definitive medical diagnostic information. To a small degree, theres some direct harm. To a lot of these things, the direct harm issue is actually pretty minor. Its more the indirect things: the diversion of resources, the delay of diagnosis or care. I think the big problem is just that the marketing campaign of the alternative-medicine proponents has been so successful over the last twenty years that theyve successfully profoundly confused the public on a lot of fundamental issues, and theyre doing a lot of harm to the practice of science-based medicine, to the education of the next generation of physicians. Things like confusing natural with safe and effective, or holistic with patient-centered, actually trying to weave these really confused and tangled arguments about the nature of science, and the relationship between science and the practice of medicine. This is all having a very insidious and negative effect on the institution of medicine and the beliefs of the public about how medicine works, and how science works. Its very hard to quantify all of that, but I definitely see it as having a tremendous negative effect. I see patients every day struggling with all of this marketing misinformation: wasting money, wasting time, subjecting themselves to needless risk, because its just in the culture now, Yes, I want a natural alternative. Meanwhile, theyre taking something which is basically an unregulated, unpurified drug with unknown content and unknown side-effects and unknown drug-interactions, and theyre spending their limited health-care dollars on this rather than on a proven treatment because theyve bought into the marketing hype. They often have no clue what it is theyre really buying. Its unfortunate that theyve been so successful in pulling off the swindle of the century, really, and in convincing so many people that their marketing con is somehow an acceptable alternative to logic and evidence.
KD: It seems like thats happening on all fronts. Little kids get it at school with intelligent design. Then we get the climate change debate. And then its in medicine, too. It just seems like people are being taught that theres a false balance, that, theres always two sides to everything.
SN: Yeah. In many ways, I think theyre sort of learning off of each other. It is again, this sort of marketing culture that has learned how to market pseudo-science, whether its intelligent design, or alternative medicine, or global warming denial, or whatever it is. I see a remarkable consistency in the kinds of arguments that are being used by all these otherwise very different endeavors. Theyre all ultimately a way of promoting an ideology, or promoting a financial interest, against the scientific consensus, and their methods are remarkably similar. Theyre largely selling misinformation, doubt, confusion, and some fairly sophisticated but ultimately anti-scientific arguments in order to undercut the bottom-line that what theyre selling is not consistent with the science.