More Medicine Does Not Mean Better Health
This chart from Our World in Data shows that the U.S. (orange dot far right) spends far more than any other country on health care and yet is far from number one in life expectancy.
OCTOBER 25, 2024, HOBOKEN. Two statistics capture the ills of American medicine: The U.S. ranks #1, by a long shot, in per-capita spending on health care. And yet the U.S. ranks #55 in life expectancy, just below Albania and Panama.
Clearly, more medicine does not result in better health. Far from it. Most treatments don’t work very well, and many do more harm than good. So philosopher of science Jacob Stegenga argues in Medical Nihilism, a dry, data-dense, devastating critique of medicine and medical research.
We should “have little confidence in medical interventions,” Stegenga writes, and resort to them much more sparingly. This is the perspective that Stegenga calls medical nihilism. What follows is an updated version of my 2019 review of Stegenga’s book.
Stegenga notes that skepticism toward medicine was once widespread, even among physicians. In 1860 Oliver Wendell Holmes, dean of Harvard Medical School, wrote that if all medicines could “be sunk to the bottom of the sea, it would be all the better for mankind—and all the worse for the fishes.”
Confidence in medicine grew with the advent of anesthesia, antiseptic surgical techniques, vaccines and truly effective remedies, notably antibiotics for infectious disease and insulin for diabetes. Stegenga calls these latter two “magic bullets,” a phrase coined by physician Paul Ehrlich to describe treatments that quell a disease without disrupting the body’s healthy functions.
Researchers have sought more magic bullets, but they remain rare. We lack cures or reliable treatments for most forms of cancer as well as heart disease, Parkinson’s, Alzheimer’s, arthritis and mental illnesses.
Many “widely consumed” medications are “barely effective and have many harmful side effects,” Stegenga says. Examples include drugs for high cholesterol, hypertension, type-two diabetes and depression.
Stegenga warns readers not to stop taking prescribed drugs without consulting a physician; abrupt cessation poses risks. But our health will improve, and our costs shrink, he contends, if we resort to treatments much less often. As Hippocrates said, “to do nothing is also a good remedy.”
Far from being anti-science or anti-medicine, Stegenga wants better medicine based on better science. He rejects “alternative” remedies, which are based on even flimsier evidence than mainstream ones. Stegenga acknowledges medicine’s strengths, saying there is “no place I would rather be after a serious accident than in an intensive care unit.”
That’s my view, too. Three years ago, an elbow that I injured playing hockey became septic; surgery and antibiotics probably saved my life. I just got my annual flu and covid vaccines, as recommended by the CDC. But Stegenga’s critique of medicine and medical research corroborates my own reporting. Here are key points:
Clinical trials are skewed toward positive results.
Everybody involved in clinical trials wants positive results. Patients are desperate to be cured and hence prone to the placebo effect. Journals and mass media want to publish good news, which the public eagerly consumes. Researchers can gain grants and glory by showing that a treatment works, and biomedical firms can earn billions.
Randomized controlled trials, the gold standard for medical research, are supposed to minimize bias. Typically, subjects are randomly assigned to two groups; one receives a potential treatment and the other a placebo. Ideally, researchers and subjects are “blind,” meaning that they do not know who is getting the treatment or placebo.
But researchers make many judgment calls as they design, implement and interpret trials, Stegenga points out. Randomized controlled trials are thus far less rigorous and more “malleable,” or subject to manipulation, than they seem. The same is true of meta-analyses, which assess data from multiple trials.
This malleability explains why results of different trials vary widely, and why industry-sponsored research is far more likely to show benefits than independent investigations. Meta-analyses of antidepressants carried out by researchers with industry ties are 22 times less likely to mention negative effects than neutral analyses. Company-sponsored comparisons of hypertension treatments are 35 times more likely to favor the sponsor’s treatment over alternatives.
More rigorous studies show fewer benefits.
Researchers eager for positive results can engage in p-hacking, which involves formulating hypotheses and finding data to support them after a study is carried out. P-hacking is a form of cherry-picking, which allows researchers to attribute significance to what might be random correlations. One way to prevent p-hacking is to make researchers “pre-register” studies, spelling out hypotheses and methods in advance.
A 2015 study compared the effect of pre-registration on federally funded trials of heart-disease interventions. Of trials carried out before 2,000, when pre-registration went into effect, 57 percent showed benefits from interventions, compared to 8 percent of the later trials, which were designed with less input from industry and more from independent researchers. Stegenga notes that on average post-2,000 interventions “did not help.”
Meta-analyses by Cochrane Collaboration, a group of independent researchers with high standards of evidence, are half as likely to report positive findings as meta-analyses by other groups. These studies suggest that the rigor of research on medical treatments is inversely proportional to treatments’ reported benefits.
Drugs’ harmful effects are underreported.
Stegenga accuses the FDA, which has close ties to industry, of setting the bar too low for approving drugs. He quotes a senior FDA epidemiologist complaining that the agency “consistently overrated the benefits of the drugs it approved and rejected, downplayed or ignored the safety problems.”
Research generally under-reports adverse effects. Preliminary “safety” trials almost always go unpublished, as do many later trials that show largely negative effects. Moreover, published studies often provide no data on patients who withdraw from a study of a drug because of adverse reactions. Medications’ harmful effects often come to light only after approval by regulatory agencies. One study found that harms are underestimated by 94 percent in post-approval surveillance.
Drugs recently withdrawn after approval include (these are generic names, Google for brand names) valdecoxib, fenfluramine, gatifloxacin and rofecoxib. Those that remain on the market despite increased safety concerns include celecoxib, alendronic acid, risperidone, olanzapine and rosiglitazone.
Health-care providers engage in “disease-mongering.”
Stegenga faults physicians and drug companies for expanding their markets by inventing disorders and pathologizing common conditions. He calls this practice “disease-mongering.” Dubious disorders include restless leg syndrome, erectile dysfunction, premenstrual dysphoric disorder, halitosis, male balding, attention deficit hyperactivity disorder, osteoporosis and social anxiety disorder.
Similarly, physicians keep “discovering” disorders in new populations. An especially disturbing example is the diagnosis of mental illness in infants. The New York Times reports that in 2014 physicians wrote 83,000 prescriptions for antidepressants and almost 20,000 prescriptions for antipsychotic medications for infants two years old and younger.
Screening doesn’t save lives.
A staple of preventive care is that screening asymptomatic people for disease leads to earlier diagnosis and better outcomes. Unfortunately, Stegenga writes, screening can lead to “false positive diagnoses, overdiagnosis and overtreatment.” (Overdiagnosis occurs when a test detects a small tumor or other anomaly that if left alone would never cause harm.)
Most evaluations of screening examine whether a test for a disease—such as mammography for breast cancer--reduces deaths from that disease compared to untested controls. Although the disease-specific method seems reasonable, it might unduly favor the test by erroneously excluding deaths resulting from the disease, treatment or test (such as a colon perforated by colonoscopy).
Hence some researchers argue that tests should be evaluated by counting all deaths, no matter what the designated cause, in screened and unscreened groups. A 2015 review examined popular tests for four major killers: cancer, heart disease, diabetes and respiratory disorders. The study found that few screening methods reduced disease-specific mortality, and none reduced all-cause mortality.
Modern medicine is overrated.
Modern medicine gets too much credit for extending life spans, according to Stegenga. In the 1970s scholar/physician Thomas McKeown argued that increased longevity results less from vaccines, antibiotics and other medical advances than from improved standards of living, housing, nutrition, water treatment and sanitation. McKeown’s work remains influential in spite of criticism.
Then there are medical errors. A 2013 study estimated that more than 400,000 “preventable hospital-caused deaths” occur each year. A 2017 follow-up study arrived at a smaller estimate of 200,000 medical-error deaths a year, which the authors say is still unacceptably high: “In what other industry would such a record be tolerated, let alone defended?”
Given all these problems, no wonder Stegenga espouses medical nihilism--or, less harshly, “gentle medicine.” Some physicians, self-described “medical conservatives,” also acknowledge the harms of over-treatment and call for less aggressive interventions. Check out the Substack “Sensible Medicine” to see how they apply their principles.
A gentler mode of medicine, if widely adopted, would promote health while reducing health-care costs. Who could possibly object?
Further Reading:
The Cancer Industry: Hype Versus Reality
Mammography Screening Is a Failed Experiment
Do Colonoscopies Really Save Lives?
We’re Too Scared of Skin Cancer
I’m a Rational Anti-Medicine Nut
Psychiatry Is Broken. Can It Fix Itself?
The Drug-Based Approach to Mental Illness Has Failed. What Are Alternatives?
Stegenga’s book complements other tough critiques of medicine, such as Barbara Ehrenreich’s Natural Causes, Robert Whitaker’s Anatomy of an Epidemic, Anne Harrington’s Mind Fixers, Gilbert Welch’s Less Medicine, More Health, Marcia Angell’s The Truth about Drug Companies and Elisabeth Rosenthal’s An American Sickness.
I learned about Medical Nihilism from economist Russ Roberts, who interviewed Stegenga on the podcast EconTalk.