In a world where Big Pharma's ads promise miracle cures between football timeouts and doctors wield prescriptions like magic wands (not me), Jacob Stegenga's 2018 opus, Medical Nihilism, drops a truth bomb: We should have "little confidence in the effectiveness of medical interventions." Ouch. That's not the feel-good script from your annual checkup, is it? But before you dismiss it as crankery, hear me out. Stegenga's thesis isn't anti-science; it's pro-rigor. Drawing on philosophy, meta-science, and a Bayesian probability scalpel, he argues that medicine's house of cards, built on biased trials, malleable stats, and overlooked harms, deserves our scepticism. In the age of over-medicalisation, a healthy dose of doubt might just save us from the cure that's worse than the disease.
Let's start with the core punch: Medicine isn't the bulletproof bastion of evidence it's cracked up to be. Stegenga frames his case as a Bayesian master argument, fancy maths for "update your beliefs based on evidence, but weigh the priors wisely." In plain English: We should assign low prior probability to any medical intervention working wonders. Why? Because history's littered with flops, thalidomide's birth defects, Vioxx's heart attacks, hormone replacement therapy's cancer links. These aren't anomalies; they're the norm in a system where "effectiveness" is often a whisper, not a roar. Stegenga crunches the numbers: Most interventions hover around marginal benefits, like a 1-2% absolute risk reduction, buried under hype. Bayes' theorem then kicks in, weak evidence plus optimistic priors equals overconfidence. Dial down those priors, factor in biases, and bingo: Nihilism emerges. We end up with low posterior belief in efficacy, even after "positive" trials.
Take the methods meat of the book, Part II's takedown of evidence hierarchies. Evidence-based medicine (EBM) worships randomised controlled trials (RCTs) and meta-analyses as gold standards. Stegenga? He calls bluff. RCTs, for all their randomisation glory, are malleable beasts: Cherry-picked endpoints, surrogate markers (like cholesterol levels instead of actual heart attacks), and exclusion criteria that make trial populations look nothing like real patients. Pregnant women out, comorbidities sidelined, voilà, a "successful" drug that flops in the wild. Meta-analyses? Even squishier. Pool a bunch of flawed studies, tweak inclusion rules or weighting, and watch results flip like a coin toss. Stegenga cites real-world whiplash: One meta says aspirin prevents heart attacks; another links it to GI bleeds. The "hierarchy" crumbles when the top rungs are rotten.
Then there's the harm hunt, or lack thereof. Stegenga's Chapter 9 eviscerates how we undercount side effects. Trials are powered for benefits, not harms, short durations miss long-term nasties, adverse events get downplayed as "mild," and pharma-funded studies? They magically report fewer risks. Remember antidepressants? Hailed for lifting moods, but the black-box suicide warnings came late, after buried data surfaced. Iatrogenic harm, doctor-induced woes, kills hundreds of thousands yearly in the US alone, per some estimates. Yet medicine's optimism bias glosses over it, turning "first, do no harm" into "first, do something, anything."
Part III seals the deal: Bias and fraud aren't bugs; they're features. Industry cash flows like IV drips, 90% of trials pharma-funded, ghostwritten papers, publication bias hiding null results. Stegenga nods to the replication crisis: Half of psych studies flop on retry; biomed's no better. Fraud? From data fudging (hello, Surgisphere scandal) to "salami slicing" results for max pubs. Values seep in too, what counts as "disease"? Stegenga's hybridism (disease as biological dysfunction plus normative harm) spotlights medicalisation: Shyness becomes social anxiety disorder; normal grief, major depression. Cue the pills, profits, and placebo effects masking meh efficacy.
Stegenga's not claiming zero wins; he's nihilistic about most interventions. Vaccines? Solid (but he is too optimistic here.). Antibiotics for bacterial infections? Game-changers. But for chronic ills, statins, SSRIs, the latest oncology blockbuster, the evidence is shakier than a Jenga tower in an earthquake. His "magic bullets" chapter skewers the myth of targeted cures; biology's messy, not a lock-and-key utopia.
Satirically speaking, medicine's like that friend who overhypes every party: "This one's epic!" — only to deliver warm beer and awkward small talk. We trust because we must, facing mortality without hope is bleak, but Stegenga urges calibrated caution. Demand better: Pre-register trials, fund independents, embrace Sir Austin Bradford Hill's pluralistic evidence (strength, consistency, plausibility, not just p-values). In 2025's post-COVID haze, where "trust the science" morphed into mandates amid flip-flops on masks and origins, nihilism feels prescient. mRNA jabs with rushed trials and variant-chasing boosters? Echoes of Stegenga's warnings.
Bottom line: How much should we trust medicine? Enough to seek it wisely, but not blindly. Stegenga's nihilism isn't defeatism; it's a call to arms for better science. In a trillion-dollar industry where lives hang on the line, scepticism isn't heresy; it's hygiene.
https://www.amazon.com.au/Medical-Nihilism-Jacob-Stegenga/dp/0198747047