Thursday, January 24, 2008

Logical Fallacies and the Discussion of Health Care Policy: Examples Courtesy of DrugWonks.com

On the DrugWonks blog, blogger Robert Goldberg seemed terribly perturbed about Health Care Renewal, and me in particular. In the last week, he devoted two posts to disagreeing, to use a polite term, with me and this blog, and threw in parenthetical comments about me and this blog in two other posts. It is not exactly clear what I wrote that set him off. He never linked to particular posts, or quoted anything I actually wrote. My best inference is what most recently raised his ire was this post about conflicts of interest related to two public pronouncements by influential health care not-for-profit organizations urging patients and physicians not to abandon Zetia and Vytorin.

His posts are entitled "Beware of All Innovations, Especially New Ones," "Sanctimony About Vytorin's 'Secret' Panel,", "Everyone has a right to their own opinion as long as they agree with me," "Why the Media and Pharma Blogsphere Fails to Get Personal."

We have previously posted about op-eds in the mainstream media written by Robert Goldberg, and his boss, Peter Pitts, which have also featured logical fallacies (here, here, here, and most recently here.) Goldberg also once used DrugWonks as a platform to try to discredit Health Care Renewal, again making use of logical fallacies (see post here).

We have noted before that Goldberg works for the Center for Medicine in the Public Interest, whose president, Peter Pitts, is Senior Vice President for Global Health Affairs at the big public relations firm Manning, Selvage and Lee. Manning, Selvege and Lee has many big pharmaceutical accounts, as listed on the CommuniqueLive.com site. Furthermore, in a post on Drugwonks, Goldberg acknowledged "CMPI accepts grant from drug companies -- and we do so proudly because they actually invent things that help people." In the op-eds noted above, neither Pitts nor Goldberg acknowledged their relationships to the pharmaceutical industry, giving us reason to label their writings in the media stealth health policy advocacy.

Goldberg's latest set of writing are notable mainly for their creative use of multiple logical fallacies. So to try to make some lemonade out of the lemons he has provided, let me respond to some of his points sorted by the kind of fallacies they represent, with discussion of the definition of these fallacies and how they were deployed. All definitions used here were from the Nizkor Project.


A Squadron of Straw-Men

The straw-man argument seems to be a favorite of Goldberg's. One working definition of the straw-man fallacy is: "The Straw Man fallacy is committed when a person simply ignores a person's actual position and substitutes a distorted, exaggerated or misrepresented version of that position." Here are some examples, in the order they appeared in his posts.

  • "the Poses postulates" - In "Beware of All Innovations...," Goldberg invented a set of exaggerated postulates purportedly for the use of pharma-skeptics. They begin with "don't trust Pharam research or the researchers they pay," and go downhill from there to "don't use any drugs...." Obviously, the first could conceivably be an exaggeration of some things I have written, and the last is plain ridiculous. Also obviously, I never proposed anything remotely like these. So this is a quintessential straw-man fallacy. Goldberg has simply made up words and then attributed them to me.
  • "this also should apply to Zocor," - In "Sanctimony About Vytorin's...," a post which starts by criticizing me as "insufferable," Goldberg seemed to imply that I suggested "people should stop taking SSRIs, Avandia, and Vytorin." He then added "now I guess this should also apply to Zocor." I have criticized the suppression and/or manipulation of clinical research about SSRIs, Avanda, and Vytorin, and noted that it is not clear that the benefits of the latter two drugs outweigh their harms. I have never had reason to directly discuss Zocor (simvastatin, by Merck), a commonly used statin lipid-lowering drug. I certainly never suggested that it not be used.
  • "anyone who consults for drug companies is a prostitute and endangers the public health," - Also in "Sanctimony," Goldberg suggests I expressed this extreme sentiment. I surely have written about concern that medical academics who also have financial ties to commercial health care firms are hard pressed not to be influenced by such ties. But I never used the p-word in this context.
  • "And he presumes that the only source of bias that affects the public health adversely - mostly without empirical evidence - is financial inducements from drug companies," - In "Everyone has a right...," Goldberg directly misrepresented my position as above. If he bothered to read Health Care Renewal, he would find that I (and our other bloggers) have been equal opportunity offenders, skewering deceptive marketing, conflicts of interests, and other such practices involving all sorts of health care organizations, not just pharmaceutical companies.
  • "By his standards, Gertrude Elion, Louis Pasteur, Josh Lederberg, Joseph Goldstein, Phil Sharp, Nobel Laureates all, are untrustworthy tools while Poses is the trusted one...," - This appeared in "Everyone has a right...." To be concrete, I don't think I have ever mentioned any of these luminaries in Health Care Renewal. More importantly, all these scientists were best known for basic research, and they all did their major work before the rise of pharma as a major sponsor of clinical research. All I have written about conflict of interest, research manipulation, and research suppression has been about clinical research, that is, research on intact human beings. I have been most concerned with influence by the manufacturers of particular products on human research that tests the products they make. The issue has never been commercial funding of basic science. So Goldberg's assertion in this case was certainly the biggest collection of straw so far.
  • "So obsessed is he with the fear of pharma infiltration of medicine and science that he casts a blind eye towards other sources of conflict." - Again, in "Everyone has a right," Goldberg demonstrates that he is not a faithful HCR reader. As noted above, we have criticized all sorts of conflicts of interest, involving not just pharma, but device, biotechnology, managed care, hospital suppliers, etc, etc. More straw piled on the camel.
  • "And who said the conclusion of ENHANCE was to lower cholesterol at all costs? Roy Poses?" - This was in "Why the Media...." Of course, I didn't say that. Enough straw-men to break any camel's back.

Accusations of Guilt by Association

A working definition, "Guilt by Association is a fallacy in which a person rejects a claim simply because it is pointed out that people she dislikes accept the claim."

  • "There is no doubt Poses is part of the 'I hate Pharma' crowd...." - Goldberg wrote this in "Everyone has a right...," This has elements of a straw-man too, since, as noted above, I have written quite a lot about health care organizations outside of pharma. Clearly, though, Goldberg has lumped me into an amorphous group whose existence is as plausible as Hillary Clinton's "vast right wing conspiracy."
  • "the failure of the I hate pharma crowd in the media and blogsphere...." - This was in "Why the media...." See comments above. I guess Goldberg doesn't think I'm in with the in-crowd.

Down the Slippery Slope

A working definition, "The Slippery Slope is a fallacy in which a person asserts that some event must inevitably follow from another without any argument for the inevitability of the event in question. In most cases, there are a series of steps or gradations between one event and the one in question and no reason is given as to why the intervening steps or gradations will simply be bypassed. " Goldberg tended to employ slippery slopes in conjunction with straw-men.

  • "the Poses Postulates" - Again, as noted above, these were certainly not my postulates. The postulates themselves were a fairly classic slippery slope, starting with exaggeration, "don't trust Pharma," proceeding through this dubious reasoning, "Don't trust the drugs they produce or market since the FDA is nothing but a tool of pharma," and ending with the ridiculous, "don't use any drugs...."
  • From "any financial ties is a conflict," through "people should stop taking SSRIs, Avandia, Vytorin. Now I guess that should also apply to Zocor." Again, this was noted above as a case of a straw-man fallacy. Goldberg constructed his straw-man so as to slide down a slippery slope.

Fishing for Red Herrings

Working definition: "A Red Herring is a fallacy in which an irrelevant topic is presented in order to divert attention from the original issue. The basic idea is to 'win' an argument by leading attention away from the argument and to another topic."

  • "Poses has also remained silent about the rash of websites that have popped up urging people to sue Merck and Schering for false claims, to stop taking Vytorin and switch to 'natural' cholesterol lowering products that they sell, etc." - Goldberg wrote this in "Everyone has a right...." Obviously, whether or not such web-sites exist, whether or not they are abusive, and whether or not I have noticed or commented on them has no bearing on whatever I wrote about ezetimibe, clinical research on it, etc that so offended Goldberg. (Goldberg actually never clearly referred in any of these posts to anything specific that I wrote, so what so offended him was never clear.)
  • Goldberg wrote two paragraphs about alleged conflicts of interest affecting the Prescription project, then "Should Poses be suspicious about the choice of drugs made by the Prescription Project based on their source of funding? Not a peep." - This again was in "Everyone has a right...." Again, this is irrelevant to the ezetimibe controversy. I have tangentially referred to the Prescription Project on this blog, but not in a way that is relevant to anything else Goldberg was talking about.

For Latin Lovers, Ad Hominem Tu Quoque

This may not be the most well-known fallacy, but its working definition is: "This fallacy is committed when it is concluded that a person's claim is false because 1) it is inconsistent with something else a person has said or 2) what a person says is inconsistent with her actions. "

  • After making the straw-man argument that I would have labelled a host of Nobel Prize winning basic scientists as untrustworthy, "while Poses is the trusted one because they take or took drug money or worked for drug companies while he Poses [sic] just got one Merck grant back in 1997-1999 (which he never declared in his blog.)" - This appeared in "Everyone has a right...." The argument seems to be that anyone who ever had a relationship with a pharmaceutical company of any type can never criticize anything to do with such relationships. (In a funny way, Goldberg thus seemed to be making an argument for how conflicts of interest do influence what people say and do.) I freely admit I was the Principal Investigator of a grant sponsored by Merck, and paid to the hospital which employed me. Why that singular relationship ten years ago should discredit my current arguments about conflicts of interest, arguments which Goldberg never directly addressed, is, to be charitable, not obvious.


Joe Collier wrote succinctly in the British Medical Journal, [Collier J. The price of independence. Br Med J 2006; 332: 1447-9.] "In my experience, people who have conflicts of interest often find giving clear advice (or opinions) particularly difficult." Goldberg's latest writing seem to demonstrate this well.

The writings of Goldberg and Pitts probably inadvertently have provided a great set of teaching cases about how logical fallacies can be used in persuasive writing to put forward dubious, and conflicted postulates. A working knowledge of logical fallacies should help readers separate the wheat from the chaff in the cacophonous clamour about the current crisis in health care. Some useful web-sites for those interested in logical fallacies are the Nizkor Project: Fallacies, LogicalFallacies.info, and the Fallacy Files. (I'm sure there are others.)

ADDENDUM (28 January, 2008) - Goldberg has also taken issue with Dr Howard Brody (of the Hooked: Ethics, Medicine and Pharma blog) and Dr Daniel Carlat (of the Carlat Psychiatry Blog), and then with Dr Aubrey Blumsohn (of the Scientific Misconduct Blog). See if you can spot the logical fallacies in Goldberg's pieces. Then see Dr Brody's reply here.

6 comments:

MedInformaticsMD said...

For the record, I believe it was Robert who invited me to speak at the Ethics and Public Policy Center's Capitol Hill Conference on Healthcare in 1999, where I presented my iconoclastic views on health IT. So, at that point in time, critical views were welcomed.

I believe Roy's views on conflicts of interest are reasonable, and that the resolution to the problems he raises is a simple one: transparency. Let the consumer then decide on the credibility of the person(s) rendering opinions on drugs.

Finally, I believe much of pharma's problems stem from a loss of understanding of Western tenets of science and 'kultur.' The placement of incompetents and/or self-serving empire builders (who I'd never have let near biomedicine let alone into positions of authority) were not the result of evil designs, merely distorted thinking about the people and skills necessary for development of new, innovative, useful drugs.

Daniel Goldberg said...

SS,

I believe Roy's views on conflicts of interest are reasonable, and that the resolution to the problems he raises is a simple one: transparency.

There's actually a wealth of evidence to suggest that transparency alone does not significantly mitigate the effects on human behavior of the relationships that lead to what Andrew Stark terms "behavior of partiality."

Machanda & Honka's recent study demonstrated that even prescribers who were aware of the likelihood that detailing influenced prescribing habits showed no difference in their prescribing habits from prescribers who were not aware of the connection between detailing and prescribing habits.

Further, as Sheldon Krimsky documents, there is reason to belive that retroactively managing conflicts of interest does little to prevent behavior of partiality, because the effects on human behavior tend to occur much earlier in the psychological process.

Look, I'm not opposed to greater transparency and disclosure. Who would be? But one idea I try to impart when I write and lecture on COIs is that the idea that we can resolve the worst problems of COIs simply by more actively disclosing and managing such COIs is flawed, IMO.

Disclosure/transparency is absolutely an important start, but it is no more than that. There is good evidence that bad behaviors that result from COIs persist quite actively even in the face of good disclosure and transparency.

The only resolution that is likely to work is to proscribe the relationships that may lead to bad behavior, just as federal conflict laws prohibit federal officials from enjoying gift relationships with advocates and the like. Unfortunately, prohibiting such relationships in a health care world which is predicated upon the connection between industry, healers, and investigators is simply impossible because of the path dependence. We can't just start over, obviously.

In any case, I'm not writing this to suggest that I have a good answer for the problem, but am saying that ameliorating the problem goes well beyond transparency, which is absolutely a good in itself.

Anonymous said...

I love the post on logics and the first comment submitted to it. I am not sure what to say except wow. In the comment, a person managed to sum up my own views with such a clear, compelling and crisp few sentences. Big phrma has moved away from the basic tenets of science and has lost its integrity.

I have worked in big phrma for 18 years now, and what I have seen is a transformation of companies that once had scientific prowess to companies that are simply marketing powerhouses and power-players that leave the science as a backdrop at best. I can't tell you how many marketing, strategy and advertising people of I seen hired from consumer product brands as phrma tried to re-shape its more direct-to-consumer branding strategy. Along the way phrma forgot that it's not selling potato chips or hair gel, it's about medicine and sometimes very serious medicine.

If there was one point I would add to a very powerful comment it is that the new version of phrma leader (fairly referred to as incompetents and empire builders) have such a short-term view that they continue to make decisions that might be good for the company in the next 3 or 4 quarters but very bad for the industry down the road. I see it over and over and over. Notably, in the modern corporate world compensation is merit based. Everyone has goals and he or she is measured against them. And at my company people say, "if it's not in the goals, it won't happen." So here is an interesting question. With phrma's reputation down at the bottom with the tobacco companies, how many CEO's have included in their own goals a direct, actionable and measurable goal to stregthen phrma or the company's reputation? I bet you will find no one. Sure there will be CEO's and Presidents who will make broad references to Missions etc but you won't find CEO's who will tie their performance to measurable reflections on the industry or the company. And there is so much data out there that could be referenced. Imagine where the industry might be if all of the CEO's simply tied 10 or 20% of their personal goals to improving phrma's reputation and stature by just 5 or 10%. I guarantee you would see at least some change (because these folks won't leave a few hundred throusand dollars on the table trust me). What is shocking is their complete failure to even try. Look at the goals of CEO's and Presidents and ask yourself what goals go to short-term success versus long-term growth and sustainability. You will see that they refuse to tie their own performance to anything MEASURABLE that is long term.

I work in phrma and I believe in the medicines. But the comment is correct, the industry has been taken over by incompetents, empire builders and greedy short-term thinkers. And we are paying a terrible price for it because just a short time ago it was a respected, productive and enormously innovative industry. Can't just one leader step forward and set an example for change.

I hope that your blog continues to do what it is doing.

MedInformaticsMD said...

Daniuel Goldberg wrote:

In any case, I'm not writing this to suggest that I have a good answer for the problem, but am saying that ameliorating the problem goes well beyond transparency, which is absolutely a good in itself.

Actually, I concede this. You are correct. I tend to be an optimist on people's behavior. Considering the behaviors I've actually observed as an adult, I can perhaps blame the overoptimistic conditioning I received in the Philadelphia schools while growing up.

-- SS

MedInformaticsMD said...

Anonymous wrote:

I have worked in big phrma for 18 years now, and what I have seen is a transformation of companies that once had scientific prowess to companies that are simply marketing powerhouses and power-players that leave the science as a backdrop at best.

See this link for an example.

Anonymous said...

Thirty plus years ago there was an unspoken understanding that sales people would never become senior managers. Those traits that make a good salesperson do not lend themselves to the type of clear critical thinking necessary for running a company. One of the overriding traits of a salesperson is the firm belief that, at the time the are speaking, no matter how outrageous, what they are saying is true. This also leads to the concept that any counter information, no matter how fact based, is wrong.

The greed of the 80's lead to the boom of the 90's and the "deal" became the buzz word in business. Nobody asked if we should do something, but how fast can it be done. Those who questioned this mentality were pushed aside in favor of those who said yes. Empire building became the standard management practice and those not going alone were labeled as "not team players" and sent down the road.

Pharma best represents this change as it has become a purely marketing industry. Strawman attacks, half-truths, and simple hack sales techniques have become the norm, and when someone points and says "The emperor has no clothes" they are shouted down.

Various government agencies are looking at pharma's science and marketing practices One can only hope they find it politically beneficial to end the marketing nature of this industry and return it to the science.

Steve Lucas