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UC Irvine UC Irvine Electronic Theses and Dissertations UC Irvine UC Irvine Electronic Theses and Dissertations Title The Fundamental Antagonism: Science and Commerce in Medical Epistemology Permalink https://escholarship.org/uc/item/4kx8g2r1 Author Holman, Bennett Harvey Publication Date 2015 License https://creativecommons.org/licenses/by-nc-nd/4.0/ 4.0 Peer reviewed|Thesis/dissertation eScholarship.org Powered by the California Digital Library University of California UNIVERSITY OF CALIFORNIA, IRVINE The Fundamental Antagonism: Science and Commerce in Medical Epistemology DISSERTATION submitted in partial satisfaction of the requirements for the degree of DOCTOR OF PHILOSOPHY in Philosophy by Bennett Harvey Holman Dissertation Committee: Professor P. Kyle Stanford, Chair Professor Jeffrey Barrett Associate Professor Kent Johnson Distinguished Professor Brian Skyrms 2015 Portion of Chapter 5 © 2015 University of Chicago Press. Chapter 6 © 2015 University of Chicago Press All other materials © 2015 Bennett Harvey Holman DEDICATION To: My father who inspired me to make the world a better place. And My mother who demanded that I love my work. I learned this, at least, by my experiment: that if one advances confidently in the direction of his dreams, and endeavors to live the life which he has imagined, he will meet with a success unexpected in common hours. He will put some things behind, will pass an invisible boundary; new, universal, and more liberal laws will begin to establish themselves around and within him; or the old laws be expanded, and interpreted in his favor in a more liberal sense, and he will live with the license of a higher order of beings. In proportion as he simplifies his life, the laws of the universe will appear less complex, and solitude will not be solitude, nor poverty poverty, nor weakness weakness. If you have built castles in the air, your work need not be lost; that is where they should be. Now put the foundations under them. Henry David Thoreau Walden No one who has not given the subject especial attention can imagine what impudent mendacity, what incredibly absurd claims, what impossible statements, are indulged in by those nostrum manufacturers who have made the physician their special prey… It is a false and pernicious theory that error should be left alone; that it will die out by itself. It may in time, but I am sure that error and fraud unattacked will live much longer and thrive much better and have many more followers than if exposed frequently and attacked boldly and unitedly. We need an active, persistent propaganda, a two-fold propaganda— propaganda among the laity and propaganda among physicians. Dr. William J. Robison (1904) ii TABLE OF CONTENTS Page LIST OF FIGURES vi LIST OF TABLES vii ACKNOWLEDGMENTS viii CURRICULUM VITAE ix ABSTRACT OF THE DISSERTATION x PREFACE 1 CHAPTER 1: The End is Nigh 7 Pharmageddon 8 A depressing case study 12 Disease-mongering 13 Advertising, reprints, and lawsuits 15 Gifts, detailers, and key opinion leaders 19 Commodification of knowledge and seeding trials 21 Pharmageddon revisited 26 Plan of the dissertation 28 CHAPTER 2: Philosophers on Drugs 30 Preface 31 Philosophers on drugs 33 The danger of relying on causal theories 34 This time with friction 37 The wrong argument 46 The wrong standard 48 Unacceptable answers 51 Error vs. manipulation 54 Conclusion 55 iii CHAPTER 3: Cuckoo Eggs, IEDs and RCTs 57 Preface 58 Introduction 58 The asymmetric war in Iraq 60 The end of major combat operations, the beginning of asymmetric conflict 61 Make yourself hard to kill 62 From hillbilly armor to MRAPS 63 For lack of a crystal ball 65 What works today 66 What to expect when you’re expecting (and you’re a Reed Warbler) 69 Animal arsenals 72 Sneaks and cheats 75 Classifying competitions 76 Epistemic arms races 78 A new hope 79 The industry strikes back 81 An epistemic arms race 83 Conclusion 85 CHAPTER 4: The Fundamental Antagonism 87 Preface 88 Introduction 88 Pecksniffian virtue (1905-1910) 92 The most important medium of advertising 95 The fine art of equivocation 98 Humbug is the order of the day 101 Whose bread I eat, his song I sing 101 One of the most dangerous forms of quackery 104 Still in the realms of superstitions (1910-1920) 106 Nobody who is absolutely worthless gets in 108 The committee on therapeutic research 111 Useful drugs 113 The editor’s salary 116 The propaganda for reform 117 Conclusion 122 iv CHAPTER 5: Why Most Sugar Pills are Not Placebos 123 Preface 124 Introduction 124 Grünbaum’s placebo 125 The crystal palace 127 The placebo control revisited 129 An alternative to placebos 133 The role of placebos in the arms race 136 In the beginning 137 The problem resurfaces 139 The discrediting of active placebos 140 Conclusion 141 CHAPTER 6: The Problem of Intransigently Biased Agents 143 Preface 144 Introduction 144 DES 145 Network structure and the bandit problem 148 The impossibility of sustained convergence to the truth 151 Choosing your neighbors 154 The Problem of intransigently biased agents and epistemic clarity 157 Conclusion 159 CHAPTER 7: Embrace the Suck 160 Preface 161 Is this philosophy 162 Medical knowledge in a social world 164 The Social Epistemological Framework 164 Pharmageddon redux 166 A pragmatic defense of social epistemology 168 Disambiguating methodological rigor and epistemic reliability 171 Broken codes are worse than worthless 172 The path of most resistance 175 Recognizing constraints on interactions and robustness 178 Misleading appearances 178 Red teaming and robustness 181 Systematic analysis 185 Envoy 186 REFERENCES 189 APPENDIX A: Statistical Analyses of an Antidepressant Trial 202 v LIST OF FIGURES Page Figure 1 Grünbaum’s Model of the Treatment Process 126 Figure 2 Grünbaum’s Model of the Treatment Process Amended 131 Figure 3 Proposed Causal Model 135 Figure 4 Idealized Epistemic Communities 150 Figure 5 Simulations on a Static Network with a Central Intransigently Biased Agent 153 Figure 6 Simulations of Dynamic Networks 156 vi LIST OF TABLES Page Table 1: Mediator Analysis of Patient Predictions 205 vii ACKNOWLEDGMENTS I would like to thank the entire admittance committee at UC Irvine LPS for giving me a chance to earn a Ph. D. in a field that I had scant previous experience with; I hope this work is the first of many that pay off that gamble. This gratitude is especially owed to P. Kyle Stanford for your continued willingness to supervise a project outside of your area of expertise. You never ceased to be able to grasp a new concept, distill its essence, and ask penetrating and challenging questions. A good deal of improvement to my ideas is indebted to your patience and willingness to first let me wander and explore unimpeded for far longer than others would deem wise and then to dissect and challenge the ultimate product of my excursions. More than one potential chapter was discarded as “less than fully baked” and as a result more perceptive ideas emerged and are included herein. My philosophical appreciation of clarity and precision were cultivated by the entire department, but especially by the instruction and the example of Pen Maddy, Jeremy Heis, David Malament, and Brian Skyrms. Thank you for showing me that obscurity of thought and writing is not equivalent to deep insight. My education would have been impoverished without the benefit of learning from my classmates Kevin Zollman, Rory Smead, Bill Orr, Christina Conroy, Tucker Lentz, Elliott Wagner, A.J. Packman, Bennett McNulty, Sam Fletcher, Cailin O’Connor, and Benjamin Feintzeig. This worked in particular has benefited from many long nights of conversations with my cohort members Ben Rin and Jim Weatherall. I'm privileged to count you both as friends. A special thanks is merited by Justin Bruner, my co-author for Chapter Six. Your nascent ability to label graph axes are an inspiration to all. I will miss the sixth floor computer lab and our long nights of simulations, PBR, and Golden Balls. I would like to thank my committee members, Kyle Stanford, Kent Johnson, Jeffrey Barrett and Brian Skyrms for their feedback on earlier drafts and their high standards for inclusion. The strength of the following argument was annealed by your critiques on earlier attempts. Similar gratitude is owed to Nancy Cartwright who sat on my advancement committee and read many draft chapters. You provided invaluable guidance, feedback, expertise that was unavailable in my home department, and a relieving assurance that the dissertation was prospecting in rich philosophical territory. From start to finish the past eight years have been made far less confusing and infinitely more productive by the administrative wisdom and genuine kindness of Patty Jones and John Sommerhauser. I will miss you both terribly. I thank the University of Chicago Press for permission to include Chapters Five and Six of my dissertation, which were originally published in Philosophy of Science. Financial support for the completion of the dissertation was provided by the Dean’s Dissertation Fellowship. Finally, I cannot find the words to convey my appreciation for Sally Geislar. Your love, support, and willingness to think through things with me have brought me through many rough patches. I feel so amazingly fortunate to find someone who can share my enthusiasm for everything from 19th century chemistry to ornithology (even if you think cuckoos are evil). Your desire to improve our world is a constant source inspiration. viii CURRICULUM VITAE Bennett Harvey vanBenschoten Holman 2002 B.A. in Biopsychology and Cognitive Science, University of Michigan 2008 M.A. in Clinical Developmental Psychology, York University 2015 M.A. in Mathematical Behavioral Science, University of California, Irvine 2015 Ph.D. in Philosophy, University of California, Irvine PUBLICATIONS (Forthcoming) ——— and Bruner, J. The Problem of Intransigently Biased Agents, Philosophy of Science.
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