Death of a snake oil salesman

My favourite TV programme, "Law & Order", last night had an excellent episode entitled "Compassion". It was from the 14th season in 2003. We get to see many TV series much later in South Africa.

The plot was roughly as follows:

A real estate swindler, turned grief counsellor/psychic medium is murdered. A female paediatric oncologist (Dr. Allisson) is arrested and charged for the murder. She happens to have been both a victim of his real estate fraud, and have also attended his "crossing over" seances.

The question? Did she kill him out of revenge (rationally), or did she kill him to send him ahead into heaven as a compassionate friend for her young cancer patients after death (insanity)?

As the episode unfolds, it turns out that the snake oil salesman (Jack McCoy's term for him) did his job so well that he fooled Dr. Allison (her sanity failing due to the stress of treating terminally ill children) into believing in his ability to communicate with the dead and in his wonderfully compassionate nature. She poisons him and sends him ahead to heaven where he will comfort her little patients after death.

Poetic justice, one might say!

I could find no indication that this was in any way based on any real event. Congratulations, however, for the script writer for the ironic story.

And no, I do not advocate that snake oil salesmen (or should it be salespersons?) and such like, be killed. Let science rather deal with them and humanely put them out of business by educating consumers.

Evidence-supported practice

The tagline for this blog refers to "evidence-supported practice". What is meant by this term?

The success of evidence-based medicine has led to the evidence-based model being applied in other fields. One of the most significant extensions of the concept came when Jeffrey Pfeffer and Bob Sutton published their book "Hard facts, dangerous half truths and total nonsense: Profiting from evidence-based management". This influential book has sparked of a movement of evidence-based management.



The evidence-based concept has not been without its critics, both medicine related and in other areas of practice. Much of the criticism has been directed at the mindless bureaucratic application of the concepts, rather than at its merits. Other criticism focussed on what the critics considered the inability of the model to cope with complexity and contextual issues.

This debate has also raged within Psychology, reflecting to some extent the tension between "therapists" and "scientists". While the term evidence-based therapy has been used, other terms such as empirically based, empirically validated and empirically evualated therapy have also been considered. The term "empirically supported therapy" gained some support (pun not intended), as it was considered to better reflect issues of complexity and context.

I would suggest that the term "evidence-supported" would be better yet. Not all evidence is empirical and empirical methods are not appropriate in all contexts.

Googling the term "evidence-supported" in various combinations gives a small number of hits, but on "evidence-supported management" there's nothing that's analogous to Pfeffer and Sutton's EBM.

We have been experimenting in a special school with the implementation of evidence-supported practices in a number of ways. These include encouraging staff (teachers and therapists) to apply evidence-supported principles in their work. We are also starting to implement the principles of evidence-supported management in the school's management, based on the work of Pfeffer and Sutton. Lastly, we're working on improving the critical thinking skills of our learners.

I'll expand on these issues in future posts.

Snake oil for rusty snakes

Terry Pratchett, fantasy author and self-declared Alzheimer's sufferer, recently stated the case for snake oil cures. He did it in his inimitable style, such that even skeptics such as myself had to take note. His speech included this gem:

"Some of them wanted to sell me snake oil and I’m not necessarily going to dismiss all of these, as I have never found a rusty snake."

Hat tip to Neurophilosophy via Cognitive Edge for the link.

Who can blame victims of currently incurable diseases should they want te keep all options open? It is easy to be dismissive and skeptical in general, but not so easy when you are faced with an actual victim desperate for a cure - any cure.

That having been said, should one be as accommodating to the quacks and charlatans who sell snake oil cures? There is, I suppose, a logical inconsistency here. How can you understand and accept the victim's use of snake oil cures and at the same time denounce the quacks or charlatans who sell them?

Should the purveyor's motives and beliefs influence your tolerance? Should one be more tolerant of a quack who truly believes in his (or her) brand of snake oil and who believes he's making a difference, as against the charlatan who through deception sells what he knows is snake oil? The motives and beliefs may be different, but the outcome is the same.

Consider this this quote from Dr John Crippen in a blog posting entitled "The Quacktitioner Royal":

"There is no such thing as alternative medicine. There is only medicine. There is good medicine and bad medicine. There are doctors and there are quacks."

Snake oil bring false hope for the victims of disease and fraudulant prosperity for the quacks. It also delays the very medical progress that could have offered real cures. Should quacks and charlatans get away with it, regardless of whether their activities are based on gullibility or fraud?

For those who still wonder about snake oil cures, the 2007 book by R. Barker Bausell entitled Snake Oil Science: The Truth About Complementary and Alternative Medicine, may give some answers. Read this review by Dr. Harriet Hall in eSkeptic.



I bow out with the strains of "Lily the Pink" running through my mind. Read all about Lily Pinkham, snake oil purveyor, here. A kindred spirit is the South African Minister of Health, Dr. Manto Tshabalala Msimang, a great believer in "natural" cures.

How David killed Goliath

Hat tip to Mind Hacks for reporting on a recent very controversial hypothesis by Prof. Benny Shanon of the Hebrew University of Jerusalem that psychotropic drugs may have played a role in Israelite religious experience. This reminded me of a neuroscientifically interesting, hopefully less provocative, example of medico-deductive reasoning that I came across many years ago.

Prof. Michael Saling of the University of the Witwatersrand Department of Neuropsychology recounted this anecdote at a clinical neuropsychology course in around 1988/9. A question in the Wits final year neurology residents' exam read simply: "How did David kill Goliath?"

The answer, as I recall (it was 20 years ago), was that Goliath being a giant, may have had a pituitary tumor. The tumor's pressure on the optic chiasm resulted in a bilateral hemianopsia (visual field defect). It also led to the weakening of the arteries in the Circle of Willis. The visual field defect allowed David to get closer to Goliath and have a more accurate slingshot. The impact and penetration of the stone into Goliath's forehead, resulted in the rupture of the arteries and severe haemorrhaging. Goliath lost consciousness, allowing David to decapitate him.

I can't recall if Prof. Saling mentioned whether any of the residents got it right!


This graphic image of a pituitary macroadenoma from eMedicine.

When preparing this post, I tried to find the origin of the theory. The first similar account seemed to be in a 1983 letter by Rabin and Rabin to the New England Journal of Medicine, entitled "David, Goliath, and Smiley's people. I was unable to get access to it online, but I found this summary of their theory by Dr. Stanley Sprecher:

Undoubtedly Goliath's great size was due to acromegaly secondary to a pituitary macroadenoma. This pituitary adenoma was apparently large enough to induce visual field deficits by its pressure on the optic chiasm, which made Goliath unable to follow the young David as he circled him. The stone entered Goliath's cranial vault through a markedly thinned frontal bone, which resulted from enlargement of the frontal paranasal sinus, a frequent feature of acromegaly. The stone lodged in Goliath's enlarged pituitary and caused a pituitary hemorrhage, resulting in transtentorial herniation and death.

As can be seen, the pathology is different from my recollection of Dr. Saling's account. A review of other possibilities by Dr. Vladimir Berginer can be found online in Medical Archaeology