Many of us seek to acquire medicine when we are ill.  Likewise, as a society we allocate a great deal of our resources to developing and providing medicines.  We do these things because we have confidence that medicine will help us achieve good health when we are unwell, or at least that it has the capability of doing so.  Is this confidence in modern medicine warranted?  In Medical Nihilism, Cambridge philosopher Jacob Stegenga argues that the confidence we place in medicine is not commensurate with the evidence for its usefulness, and thus, we would be wise to dramatically lower our expectations that medicine is effective.  What Stegenga is advocating is medical nihilism.

           Nihilism is a strong term – it might denote extreme skepticism or a view that beliefs are unfounded.  Nihilism towards medicine is not new.  As Stegenga shows in his introduction, history has not always been kind in its view towards physicians and the medicines they prescribe.  Such a view is perhaps best illustrated in the opening sentence to Ivan Illich’s Limits to Medicine, perhaps the most famous work of medical nihilism, where he claims that “the medical establishment has become a major threat to health” (Illich, 1975; p.3).  Stegenga’s nihilism is a bit softer than that espoused by Illich.  To Stegenga, “medical nihilism is the view that we should have little confidence in the effectiveness of medical interventions” (Stegenga, 2018; p.1).  It is also more focused; his is a nihilism about the effectiveness of therapeutic interventions (i.e. those medicines we are prescribed or acquire), and not of the whole enterprise of health care.  Furthermore, it is a claim about medicines generally, and not to be confused with “a tough skepticism espousing low confidence about this or that particular medical intervention” (Stegenga 2018; p.2).

          Early chapters of the book are focused on defining both disease and effectiveness.  Stegenga adopts a position of hybridism, under which a something is a genuine disease only if it satisfies two conditions: 1) it involves biological dysfunction (i.e. a causal basis), and 2) the dysfunction is harmful (i.e. a normative basis).  A therapy is defined as effective only if it modulates at least one of these conditions (i.e. it intervenes on the “causal target of effectiveness” and/or the “normative target of effectiveness”), and a therapy can only be effective if it targets a genuine disease.  On its face, that view on disease and effectiveness seems reasonable.  However, a strict commitment to that view on effectiveness may be problematic.  Consider Stegenga’s example of those cases of depression that are “normal responses to the many difficulties of life and do not involve a departure from normal functioning (call these quotidian cases)” (Stegenga 2018; p.24).  Stegenga claims that such cases do not constitute genuine disease, and thus, antidepressants, by definition, cannot be effective in treating quotidian cases.  Why that should be the case is not clear – one can imagine that patients with quotidian cases of depression whose mood improves from the use of antidepressants might see that therapy as effective, irrespective of whether their condition meets the definition of a genuine disease.  This view on effectiveness further constrains the focus of Stegenga’s nihilism.

          The source of Stegenga’s nihilism is his concern about the way in which evidence that medicines/therapeutic interventions are effective is generated through medical research.  Much of the book is devoted to showing the malleability of methods commonly used in clinical research, and some of the blind spots in the current approaches to generating evidence (in particular, generating evidence on harms).  That examination is the strength of the book, and a should be of great interest to clinical scientists, those interested in research methods, and users of clinical research.  The particular issues that Stegenga raises about clinical research serve as much of the basis for the conclusion of his master argument, i.e. that we should have low confidence in the effectiveness of a medical intervention.

Overall, Stegenga’s argument appears compelling, or in the very least provocative.  Furthermore, it is necessary if for nothing more than to temper the enthusiasm for the information derived from clinical research, for which there is much enthusiasm that is unwarranted.  Nevertheless, there are some aspects of Stegenga’s argument that give this reader reservation in fully adopting a view of medical nihilism.   I think Stegenga goes too far in his concern for medical research.  It may be the case that such methods are too often abused in favour of showing a positive benefit of a therapy, but it is also the case that such methods can often be used to produce valid estimates of effect (indeed, Stegenga leverages the latter to show evidence of the former).  Admittedly, when research methods are used and interpreted responsibly the resulting data does reveal little or no effect for some therapies; such cases do advance Stegenga’s thesis.  However, that methods can be abused or that we are sometimes wrong in our estimates of effectiveness should only teach us to be humble in our interpretation of or enthusiasm for research findings – humility is a far cry from extreme skepticism or nihilism.  Stegenga also seems to attribute too much relevance to the general concern about the malleability of medical research when assessing the particular case of therapeutic effectiveness.  Consider his statement that “medical interventions ought to be assessed empirically on a case-by-case basis.  However, such assessments ought to be construed broadly to include the frequency of failed medical interventions” (p.2).  Canonical errors, such as publication bias or sampling bias, should make us more vigilant in how we assess the evidence value of a specified research base on an estimate of effectiveness for a specified medicine, but they should not cause a categorical downgrading of confidence in the particular estimate by virtue of the fact that such errors can exist and/or often do exist in other circumstances.  Again, the need for vigilance is a far cry from nihilism. 

Stegenga advocates for “gentle medicine”, in that “we should consume fewer medical interventions, physicians should prescribe fewer interventions, and policy makers should approve fewer interventions” (p.185).  The arguments put forward in this book support that claim, even if they do not support (in my opinion) a call for nihilism.  As a whole, the benefits of medicine are overstated – Stegenga’s does a very good job showing the reader why that is the case.  Should we be nihilists about medicine?  I would not go that far, but I do see his thesis as a much needed call to temper our enthusiasm about the enterprise of medical therapy.

References

Stegenga, Jacob.  Medical Nihilism. Oxford: Oxford University Press, 2018.

Illich, Ivan.  Limits to Medicine: Medical Nemesis: The Expropriation of Health (reprint).  New York: Marion Boyars, 2016.

© 2018 Mathew Mercuri

Mathew Mercuri, Assistant Professor, Division of Emergency Medicine, Department of Medicine, McMaster University