What Does a Medical Nihilist Do When He Gets Sick?

In my recent column “Is Medicine Overrated?,” I review Medical Nihilism, a blistering critique of medical research and practice. Author Jacob Stegenga, a philosopher at the University of Cambridge, argues that we should “have little confidence in medical interventions” because most do not work very well.Moreover, clinical trials tend to overstate the benefits and understate the risks of medications. I found Stegenga’s thesis all too persuasive, but his book left me with lingering questions, two of which I emailed to Stegenga. He answers them below. I also wanted to publish a graph showing that deaths from tuberculosis started falling well before the advent of vaccines and antibiotics. It corroborates Stegenga’s claim (which he credits to physician/scholar Thomas McKeown) that modern increases in longevity stem more from improvements in nutrition and sanitation than from medical advances. My thanks to Keith Riggle for sending me the graph. –- John Horgan

Horgan: Why don’t vaccines count as magic bullets? Haven’t they helped boost health and longevity over the past couple of centuries? And also, what about huge decreases in infant and maternal mortality? Shouldn’t medicine get credit for those? 

Stegenga: Regarding your question about vaccines, yes, they are a certain kind of magic bullet, and they are obviously hugely important in medicine. Since I define ‘magic bullets’ narrowly, as interventions that target the pathophysiological basis of disease, then vaccines can’t be construed as magic bullets on that narrow construal, but that’s merely definitional — we could just introduce a new concept for preventive medications in general, like “magic shields.” I’d argue that vaccines are magic shields, while many other widely prescribed preventive interventions, like statins, are not. But anyway, the short answer is that vaccines are obviously hugely beneficial interventions; arguably most of the most important vaccines, such as the polio vaccine, were developed during the golden age of medical discoveries, from roughly 1920-1960 (along with penicillin and insulin, two of the running examples in the book). 

As for the decrease in infant and maternal mortality, here too of course I agree that medicine should get credit; what I’d suggest, though, is that these kinds of gains in medicine were the result more of antiseptic techniques and improved nutrition rather than exogenous medical interventions per se. This is in line with the “McKeown thesis,” which holds that the decrease in mortality and increase in longevity and population size since the industrial revolution is largely the cause of things like better nutrition (and sanitation, clean drinking water, etc.) rather than pharmaceuticals (I mention this argument in a couple of places in the book).

Horgan: Another question, and if you prefer not to answer I understand: Have you advised any friends/loved ones to stop taking statins, say, or antidepressants? Do you get regular checkups? If you were diagnosed with, let’s say, melanoma, would you forego treatment? I’m just curious about how much your intellectual views have permeated your personal life. I’ve struggled with this myself, especially when it comes to advice to others.

Stegenga: I avoid giving medical advice to anyone, including friends and loved ones, though occasionally friends will ask me about a recent study they had read about on, say, antidepressants, and I’ll discuss the study with them. So I avoid giving personal advice, but I certainly hope my book can help people make better choices about medicine. 

For myself, I don’t get regular check-ups, though this is a modest stance because I’m generally very healthy. But certainly my intellectual views on medicine influence my personal decisions. Several years ago I tore my ACL playing tennis, and my treating physician called himself a “non-interventionist,” which I didn’t at the time understand. But he directed me to several recent randomized trials which compared a regime of physiotherapy and exercise to surgical reconstruction, and the less interventionist regime of physiotherapy got patients to similar endpoints as surgery — so I opted for no surgery. 

But if I had a disease for which I thought there was a truly effective intervention (“magic bullet,” to use the term from the book), then I would of course use this intervention. The most recent time I made a trip to a physician, I was diagnosed with shingles, and there was little to be done to help except prescribe treatments to ease the pain and itching. This strikes me as a pretty good illustration of some of the themes from the book; and indeed, one thing medicine can often do well is decrease pain (which is of course important) — though, given the current opioid crisis, many people are now saying that medicine has gone way overboard in trying to manage pain.

Further Reading:

Is Medicine Overrated?

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Meta-Post: Posts on Mental Illness

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