In an earlier post I suggested that systems medicine, a new approach to medicine which applies the ‘big data’ approach of bioinformatics, offers substantial promise, but also faces profound challenges, not least the question as to how integrate multifarious sources of evidence in order to discover new causal relationships.
The Reasoner is a monthly digest highlighting exciting new research on reasoning, inference and method broadly construed. It is interdisciplinary, covering research in, e.g., philosophy, logic, AI, statistics, cognitive science, law, psychology, mathematics and the sciences. In this month’s issue you can find a report on the workshop held at the University of Kent last month on Evidence of mechanisms in evidence-based medicine.
An article recently appeared in Science investigates the correlation between the frequency of tumours (all, indistinctively) and the number of stem cell divisions. The correlation, the authors of the article say, is very strong. This is potentially very significant and informative, except that, unfortunately, only a very small proportion of the variation in cancer risks can be attributed to environmental factors or inherited predisposition. The rest – which is a big chunk to explain – is due to bad luck. I refer the reader to a clear article by Paolo Vineis, where he expresses doubts about the methodology of the paper.
But this is not the point I want to reflect on. I am instead most interested in the explicit use of the term ‘bad luck’, which occurs both in the text of the authors and in the editor’s comment accompanying the article. Needless to say, this is the only aspect that the media picked up (just google ‘bad luck cancer’ and you will realise how much this is resonating).
There is a lot that we don’t know about cancer (and about many other phenomena). But is it ‘bad luck’ if we get ill and we don’t have a cause to blame? Is everything we are unable to explain today due to chance? What kind of message do we convey to the public in this way? The issue is of course delicate, because we find – at the other end – another extreme position: scientism. And surely we don’t want to fall on that side either. While it is intellectually honest to say that we don’t know something, it is misleading to call it bad luck. In the case of cancer, the message can be devastating. If bad luck plays a major role in cancer development, why bothering with prevention and with screening? (This doesn’t imply, however, that all preventive actions are sound or effective, or that screening programmes always lead to correct identification of cases of cancer.)
Also, what the article labels as ‘bad luck’ may be in fact due to factors that have not been thoroughly explored, for instance socio-economic or behavioural factors. I’m not talking about reducing the ‘social’ part of disease to some allegedly objective, bio-chemical element. I’m really talking about understanding the lifeworld of individuals, which includes health and disease.
In sum, ‘bad luck’ is really a bad choice for a scientific article, not just because it shows epistemological clumsiness, but also because it may have quite undesirable consequences on the public understanding of science and on people’s behaviour.
Do you want to do a PhD on a topic related to EBM+? If so, do get in touch with one of us.
Current funding opportunities include:
Topics connected to EBM+ are also coverered in Masters programmes in Medical Humanities and Reasoning at the University of Kent and in History and Philosophy of Science at UCL.
It’s almost the last workday of 2014 for me today, and a busy last few weeks means that I’m looking forward to the Christmas break. All things being well, I’ll be able to spend some quality time with two books that I’ve been meaning to read for ages.
Götzsche, Peter. 2013. Deadly Medicines and Organised Crime. Radcliffe.
The first of these is not, I’m afraid, cheerful holiday reading. In fact, if you’d like a brief summary of the most important bit of Gotzsche’s argument, the title of a recent paper – Our prescription drugs kill us in large numbers – tells you most of what you need to know. The book follows on from this: page 1 begins with the quote “drugs are the third leading cause of death after heart disease and cancer.”
This is shocking stuff, which becomes even more troubling because of the lucid way that Götzsche lays out his evidence in support. The mechanisms by which drugs became so dangerous are largely down to the pharmaceutical industry. I’m planning a proper review of the book for some time in the new year, but by way of a taster, Götzsche argues that drug companies are largely free to mislead clinicians about both the safety and efficacy of drugs, and that this impunity has largely come about through a shortfall of regulatory oversight.
This brings me to my second lump (affectionately!) of holiday reading, which deals with the big-daddy of the pharma regulators: the FDA. Götzsche argues that the FDA has become an environment that is completely subordinate to the drug industry. But I think that there might be more to say on the historical side here. Luckily, so did Daniel Carpenter, whose book deals with just that.
Carpenter, Daniel. 2014. Reputation and power: organizational image and pharmaceutical regulation at the FDA. Princeton University Press.
This book came out of the FDA project at Harvard. This seems surprising to me, given that the book itself was published by a different Ivy League press. But no matter what intrigue may have lead to this route of publication, I’m told that is a startlingly thorough and penetrating account of how the FDA came to be. Until I’ve spent much more time with it, though, I’ll hold off trying to summarise 700-odd pages of detailed argument.
Whatever you think of Peter Götzsche’s overall analogies between the pharmaceutical industry and members of the Soprano family, I think that trials conducted in secret have to be of concern. That’s why I’m also making a new-year’s resolution to be more vocal in my support of the AllTrials campaign. You can find out more on their website, but the least that you need to know is that…
AllTrials calls for all past and present clinical trials to be registered and their full methods and summary results reported.
I’m signing their petition, and urge you to sign too, largely because finding things out in medicine is already hard enough without concealed trial results.