[At the outset, i'll clarify that i have the utmost respect for the doctors and the profession in general. They are in the profession of health, life, survival, healing and more importantly - alleviating suffering. What can be more important to humanity than this? ]
Medicine is a wide area. There are areas where cause and effect is easily discernible. If there is a fractured arm - we know what to do. There are many aspects of the body that are mechanical and electrical in nature and hence greatly helped by advances in technology - say the hearing aid or progressive lenses or prosthetic limbs
It is important to remember that medicine is in the business of survival, NOT TRUTH. Because seeking truth means understanding 'Life' and the very hard problem of 'Consciousness'. Only the sages have those answers because of their direct experience. Most of the medical science eschews this problems (in)conveniently and look only at the effect to make inferences.
There are many areas in our body that directly falls under the ambit of 'Complex systems'. Our BS detector should vibrate vigorously when someone makes sweeping statements in those areas.
Having said about complex systems earlier, the puritanical (or sensible) approach to our body and health would be
- Use prevention: In medicine, stopping someone from smoking has fewer adverse effects than giving pills and treatments.
- Approach via Negativa:
Why? Addition to complex system is intervention. You do not intervene a complex system because you will not know the results. Avoidance is simply not messing with the existing system and a more robust way of handling your health
The Hippocratic oath says, 'First, do no harm' and do we know for sure?
- Instead of disease, look at health and work on that
- Instead of diet, look at fasting
- Look for Lindy: Check on the habits people who survive long. They must be doing something correct
- Be Anti Fragile: Develop equanimity and strength of mind that will help you deal with tail events that you’ll anyway be exposed to in life.
- Avoid harm and ruin from tail events: for the patient this means, to avoid treatment when he or she is mildly ill, but use medicine for the “tail events,” that is, for rarely encountered severe conditions.
(The problem is that the mildly ill represent a much larger pool of people than the severely ill—and are people who are expected to live longer and consume drugs for longer. Pharma has incentives to target the large pool. I'll touch upon Bad Pharma in a bit)
Commonly used refrains are: 'Look at the advances made in the last 20 years. At this rate we can produce consciousness.'
We will become increasingly adept at replacing body parts and will make tremendous progress in various other areas of the body. But, it's a mistake to extrapolate this to the complex areas of the body. There this statement is self-delusional. We will still make new theories, reject old theories, bring back a old theory. It will be a fertile area of wallowing in BS and self congratulation. If you have any doubts about it, check nutritional claims
So to all the complex areas of the body ... apply the BS Detector ruthlessly however rosy a picture one may paint. Even when it seems to work, it is just randmomness at play and you can be ruined by unforeseen event. What is needed is anti-fragility, not some deceptive smart solution in randomness
This is where one has to be careful. We can use very simple theories - they NEED NOT BE THE TRUTH, as long as it achieves the purpose (survival, healing, reducing pain). That's why we needn't look for truth in medicine because one can't do that in complex areas. What is important are the outcomes. And that puts us directly in the area of Statistics and Probability
Allopathic and Western Medical science in general
- Treats the symptoms not the cause. In most of the cases, cure comes from our body's own self healing mechanism. The healer is inside. The external intervention is just to quieten the mind and body to the discomfort and let nature take its course
- Uses a reductionist approach. As long as there is not a holistic approach for a system like our body, we will wallow in BS. It will be an endless game of finding new chemicals, correlation and new theories. Why? Because we are Complex systems ... we are sampling various marker signals in a complex system to try to effect a cure ... that is BS
- Causality is a bitch and direction of causation even more so
- Have Side effects. Why? If you intervene a complex system you don't understand, you will mess with things
- Long term usage is unknown. This is dangerous ...because the statistics which is the cornerstone on which efficacy is predicted, becomes useless if you look at a longer horizon because of the confidence intervals.
- Higher order effects - this is because of the myopic view and simply the lack of unifying thesis of the body
As if all of the above things are not enough we have three big villains
- Bad Pharma
Pharmas have wrong incentives and hence their ethics can become questionable
The science behind them is shaky - make chemicals, test, prove efficacy. This kind of intervention in a complex system is the equivalent of spray and pray.
Pharmas can be bad actors. It's an important thing to remember and something we can't do anything unless we change their incentives
- Bad Doctor
Another Bad actor. For all the respect i have for the doctors and the profession, many are aligned on the wrong incentives. So the interventions they suggest can also be wrong
- Bad Science
Use of statistics and probability to make random inferences. This combined with the ethics and incentives can become an intractable problem to solve.
Establishing causation is at the heart of it. As we have seen causation is a bitch in complex areas
The only reasonable way we can get confidence in an intervention is to do a randomised control trial (RCT). If you are convinced that this is infallible, ask yourself why Fat was implicated as a culprit for more than a century?
It's a combination of Bad Actors (Sugar industry), Bad science and Bad Doctors
Why RCT - our best bet, can be derailed in different ways,
- Selecting control group
When you don't know causality. On what basis will you select?
You can only hope whatever that is 'causal' is available randomly and equally in the control group as well as the test group.
There is an element of chance involved here
Let's say that the actual truth about immune response to any medication is actually governed by the enterotype of the biome in the gut. If by chance we get a skewed distribution in the control group and test group, we are looking at bias
Random assignment helps reduce the chances of systematic differences between the groups at the start of an experiment and, thereby, mitigates the threats of confounding variables and alternative explanations.
This is the best that we can do here.
- Heisenberg effect - Complex system can behave in a different way when observed.
- Our body is not an automaton with fixed states, triggers and transitions. Mind is a big variable. Double blind tests are designed to mitigate this
- Duration: This is an intractable problem. Doing a long term statistical study on a considerable population worthy of statistical analysis is virtually impossible. Even if you are ok with the costs, the environment control, the real world connection and simply handling the habits of the population over an extended period means we will have to deal with larger confidence intervals and errors in estimates.
- Unknown independent variable causes bias in the model - can't do anything here. Hope for the best
- Model fitting in the higher dimension - can become the game of connecting the dots and finding patterns in randomness when none exist
- Higher order effects and feedback in the system can cause the system to behave in unpredictable ways - can't do anything here
- Causality direction - this is super difficult to establish.
- Controlling variables in a complex systems means the absence of some of the stressors that work in a complex system. These can lead to unwanted effects that can affect the outcome
- Random inference: With all the above difficulties we have to have good interpretation and inference and be able to deal with a larger margin for error.
So the upshot of all of this is the equivalent of someone saying, 'Well, i don't know how the system works. But i will intervene it in many different ways, simplify it at will to reduce complexity and interpret the results and feel good about it'.
If someone says this even to an external inanimate system - say investing money in a financial system - we'll be petrified ... but we don't blink twice about doing this to our body.
I'm not saying i have all the answers. As outlined, i can only take the puritanical approach and try to avoid harm. What i do expect from medicine though is a high dose of humility to understand and accept that we have no clue of the system. We have to respect nature and the innate intelligence of the body to heal itself.
Have kindness, compassion, and ethics to the highest level and work with a service mindset.
