Tuesday, March 28, 2017

#1815: Ted Kaptchuk

Ted Kaptchuk is a Professor of Medicine and Professor of Global Health and Social Medicine at Harvard Medical School, which has become notorious for its efforts to legitimize quackery, and most famous for his research on the placebo effect. He has also been an expert panelist for the FDA, served on numerous NIH panels, worked as a medical writer for the BBC, and is quite a big deal in certain quarters. He is accordingly one of the most influential woo apologists alive. Despite his current position, Kaptchuk lacks formal training in modern medicine or biomedical science. Instead, he has a “degree” from the Macau Institute of Chinese Medicine.

Kaptchuk rose to fame in the 80s with his book The Web That Has No Answer: Understanding Chinese Medicine (Andrew Weil himself wrote the foreword for the second edition), discussed here, which is an ambitious attempt to defend traditional Chinese medicine (TCM) through appeal to tradition, special pleading and handwaving. Kaptchuk claims that TCM is very successful, but admits that “studies generally demonstrate that traditional Chinese medicine does work best when left in the context of Chinese logic;” that is, it doesn’t seem to work so well when you use ordinary standards of evidence and you should therefore apply different standards (apparently this is because Western medicine is terribly reductionistic whereas TCM treats the whole person, which one would think would be rather irrelevant when evaluating health outcomes); TCM, you see, is according to Kaptchuk “internally consistent” (it really isn’t, if Kaptchuk’s claims are taken as a guide), and that is apparently evidence enough. As you’d expect, the book contains some interesting contradictions that Kaptchuk tries to brush over with New Age fluff (e.g. that TCM “has standards of measurement that allow practitioners systematically to describe, diagnose, and treat illness,” but “[i]ts measurements, however, are not the linear yardsticks of weight, number, time, and volume used by modern science but rather images of the macrocosm;” perhaps this is an example of the aforementioned “Chinese logic;” Kaptchuk’s book is crammed with offensive orientalism), and the fact that TCM gets the function of most of our organs wrong just means that it has an alternative anatomical theory (that should apparently not be taken entirely literally because it is pretty obviously false and Kaptchuk is working under the presupposition that the theory is correct), just like prescientific Western medicine applied an “alternative anatomical theory” until practitioners began to study how the body actually works a couple of centuries ago. Kaptchuk does assert, though, that “Western clinical studies (done in China) of traditional Chinese medicine, by proving its practical efficacy, have helped it win its battle for survival in the twentieth century, and promise it a place in the future of medicine,” but admits in a footnote (that most readers won’t see) that the studies in question weren’t really studies – they weren’t controlled and used “imprecise assessment methods. They would most properly be called clinical observations.” He doesn’t even seem to try to back up claims like “Chinese remedies are often more effective than Western ones, and they are always gentler and safer[;] Chinese prescriptions, for example, do not produce side effects because they are balanced to reflect a patient’s entire state of being” or “Chinese medicine, because it emphasizes balance and relationship more than measurable quantity, can also frequently discover and treat a disorder before it is perceptible by the most sophisticated Western diagnostic techniques[;] Chinese medicine is capable of touching those places that evade the microscope;” oh yes, he is referring to subtle energies, no less. In the book, he does not discuss how traditional Chinese medicine came to the fore in modern China, which you’d think would be rather important framework information.

After his breakthrough (and influential) book Kaptchuk spent several years championonig various forms of alternative medicine (he seems to be still shilling for TCM), including follow-ups like the Chinese Herbal Medicine: Materia Medica (with Dan Bensky and Andrew Gamble). Currently, he is most famous for his research and “research” on the placebo effect, but his background matters (though he seems, in fairness, to have shied away from defending the most egregious forms of quackery). Kaptchuk still doesn’t seem to mean by “placebo effect” what real researchers mean; rather, placebo is to Kaptchuk powerful, mystic medicine and the power that ultimately legitimizes the altmed practices that he has already convinced himself are efficacious – appealing to “placebo” is a matter of finding a framework of promoting them that might look palatable to those who care for evidence and experiment if they don’t look too closely. He has even suggested that various “CAM” treatments may have “enhanced placebo effects,” effects that are even stronger than specific biomedical treatments. I assume most people realize that “enhanced placebo effects” is a contradiction in terms if “placebo effects” is used to mean what it in fact means, but apparently some of Kaptchuk’s fans don’t. Indeed, for Kaptchuk, “placebo effect” is understood as a postmodern deconstruction of the current authoritative role of randomized controlled trials (RCTs), that reliance on evidence obtained through rigorous testing is really just a cultural contingency, and our predilection for evidence and testing an imperialistic scheme used to dismiss the types of alternative practices Kaptchuk has convinced himself work by not relying on evidence and testing. In his 1998 article “Powerful Placebo: the dark side of the randomised controlled trial,” for instance, Kaptchuk characterizes RCTs as “self-authenticating”: “In a self-authenticating manner, the double-blind RCT became the instrument to prove its own self-created value system.” As you’d expect, the article uses legitimate shortcomings with RCT to imply that altmed that show no effect in RCTs is just as good as real medicine, just like flaws in airplane design is evidence that flying carpets exist (hat-tip: Ben Goldacre). Not that Kaptchuk seems to have a particularly firm grasp of how confirmation works in any case.

When reporting his research on the placebo effect, Kaptchuk has defended active use of placebo in patient treatment for conditions like asthma: “placebo treatment is just as effective as active medication in improving patient-centered outcomes.” Of course, placebo treatments for asthma have no effect on objective measures of lung function – only on subjective measures – so Kaptchuk’s position requires quite a redefinition “patient-centered outcomes”, but such redefinition often seems to be what Kaptchuk is trying to promote. (Apparently he is partly influenced in the effort by anthropologist Daniel Moerman, whom Kaptchuk has worked with and who seems to think that healing responses are cultural constructs – Moerman is a seriously dangerous nutter.) Contrary to Kaptchuk’s claims, “harnessing the power of placebo” is of little clinical value, at least if one is clear about what the placebo effect is. For Kaptchuk, though, promoting the powers of the placebo effect still seems to be primarily a ploy to legitimize a variety of non-efficacious altmed treatments, and rebranding CAM as “medicine harnessing the power of the placebo” has actually become quite athing.

Kaptchuk has even (in an article coauthored with Michelle L. Dossett, Roger B. Davis and Gloria Y. Yeh), promoted homeopathy as a means to achieve “reductions in unnecessary antibiotic use, reductions in costs to treat certain respiratory diseases, improvements in peri-menopausal depression, [and] improved health outcomes in chronically ill individuals.” It should be needless to say that the evidence supports no such claim. The article refers to the article “A critical overview of homeopathy,” which Kaptchuk coauthored with Wayne Jonas in the Annals of Internal Medicine, suggesting that “Homeopathy deserves an open-minded opportunity to demonstrate its value by using evidence-based principles.” Well, evidence-based approaches have been used to investigate homeopathy; it’s been refuted, but somehow Dossett et al. selectively chose to miss that part, as promoters of homeopathy are wont to do.

Diagnosis: Kaptchuk has, in fact, done quite a bit of serious work. But he is also spinning that work in a manner that support an agenda of legitimizing quackery. As a result, he has managed to become one of the most important and influential apologists for woo in the US; he is currently very influential, and very dangerous.

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