Theory vs. Evidence: Unconscious Bias in Medical Decisions

Forthcoming in Journal of Controversial Ideas, April 2025

To this day there exists little good evidence that such bias warps clinical decisions—certainly not enough to bear out the sweeping theory of a psychological mechanism that operates automatically.

Was Thalidomide a Placebo Hypnotic?

 Journal of the Royal Society of Physicians of Edinburgh 54 (2024): 161-64. 

It appears that unbeknownst to themselves, an untold number of pregnant women incurred the risks of a teratogen in return for the benefits of a sugar pill.

What If Perceived Discrimination Isn’t the Same as Real Discrimination?

Forthcoming in Journal of Controversial Ideas, April 2024.

Literature that assumes that medicine is polluted with concealed bias validates misperceptions, foments mistrust, and sends the incautious message that black patients can expect poor treatment. 

Tales of the Psychosomatic in the Lyrical Ballads

Hektoen International, Fall 2023

Two of the Lyrical Ballads bear out Wordsworth’s claim that “the power of the human imagination is sufficient to produce such changes even in our physical nature as might almost appear miraculous.”

Can Belief Be Compelled?

The record of Salem shows that power can shake our foundations, pervert our conscience, fracture identity, compel beliefs

From Blocked Flows to Suppressed Emotions: The Life of a Trope

Medical Humanities, March 2022

The dangers of suppressed urges and passions continue to resonate even though medicine no longer speaks of corrupted humours or the poisons bred in the body by occluded channels and outlets.

 Musical Evenings on HMS Bounty 

The Guilt-Free Psychopath

Philosophy, Psychiatry & Psychology 28 (2021): 87-104

Reality may not conform to type.

Buried in Silence: Homosexuality and the Feighner Criteria
Philosophy, Psychiatry & Psychology 27 (2020): 283-98
The anomaly of a soon-to-be-revoked diagnosis in a set of allegedly validated criteria never became a topic of public discussion or comment in the literature.

The Weight of a Term: “Substantial Evidence” and Buried Data
Perspectives in Biology and Medicine 61 (2018): 201-14  
When Congress amended the Food, Drug, and Cosmetic Act in 1962 to ensure the efficacy of drugs before they reach the market, it set a standard of evidence distinctly weaker than the reasonable one of preponderance.

When Checklists Were New: The Prototype of DSM’s Operational Criteria
Ethical Human Psychology and Psychiatry 20 (2018): 17-26 
With the triumph of the DSM diagnostic system and Major Depression in particular, a checklist that originally served as a device for research into an imperfectly understood disorder, and was not proposed for general adoption, reified and became a formula for diagnosis on a mass scale.

James Lind and the Disclosure of Failure
Journal of the Royal College of Physicians of Edinburgh 47 (2017): 384-87  
In confessing his lack of an unfailing remedy for scurvy and his trouble making sense of the disease’s behavior, Lind did medicine a greater service than by conducting his now-famous trial.

Montaigne on Medicine: Insights of a 16th-Century Skeptic
Perspectives in Biology and Medicine 58 (2015): 493-506
In the world of Montaigne’s Essays the imagination can both induce and relieve impotence.  By analogy, it has been shown that simply informing men of the low risk of sexual dysfunction associated with a beta-blocker can increase the incidence of that adverse effect dramatically, and that the resulting dysfunction can be reversed with placebo.

The Nocebo Effect: Overdiagnosis and Its Costs
Palgrave Macmillan, 2015 
As normal conditions are branded as medical issues, they acquire powerful, suggestive labels that readily come to life in our minds and bodies. (Available on Amazon.com)

Pills in a Pretty Box

In Placebo Talks: Modern Perspectives on Placebos in Society, ed. Amir Raz and Cory Harris (Oxford University Press, 2015)

The Medicalization of Misspelling: DSM and the Management of Life
Academic Questions 28 (2015): 322-33  
To a hammer everything looks like a nail, and to the DSM everything, even misspelling, looks like a disorder.

Can I Author Myself? The Limits of Transformation
Journal of Medicine and Philosophy 40 (2015): 511-28 
It would be surprising to say the least if we could modify our very selves as readily as we can and do modify our self-narratives.

Trauma for Everyone: How PTSD Became the Malady of Millions
Published for e-readers by Now and Then Reader, May 2015 
PTSD comports uneasily with the DSM diagnostic system, and one doubts that the implications of mixing psychiatric diagnosis and oppositional polemics were well thought out at the time.

ADHD: Diagnosis and Stereotypy
Ethical Human Psychology and Psychiatry 17 (2015): 135-44  
Like a stereotype, the ADHD diagnosis is highly connotative, distorts interpretation, replicates itself and marks its objects.

The Finasteride Riddle
Journal of Symptoms and Signs 3 (2014): 154-59 
It’s because PSA testing grew into a mass movement, with the excesses inseparable from such a movement, that the urologists who set this phenomenon going are now looking for ways to rein in its harms.

The Folly of Systems: The Satiric Tradition and Mental Disorders
Philosophy and Literature 37 (2013): 472-85
“Who can sufficiently speak of these symptoms?” asks Burton.

Deception and Transparency in Placebo Research
Yale Journal of Biology and Medicine 86 (2013): 323-31 
The trickery of placebo experimentation goes beyond straightforward lies to include artful ambiguities, half-truths, and deliberate omissions in informational scripts and “verbal suggestions.”

Placebos in the Clinic
Journal of the Royal Society of Medicine 106 (2013): 208-09  
The preference for placebos with a semblance of medical legitimacy suggests that doctors are uneasy with the practice of deception even if they are not about to abandon it.

To Feel What Others Feel: Social Sources of the Placebo Effect
University of California Medical Humanities Press, 2012 
A humanist looks at the placebo effect, taking into account both its history and its ambiguity, and bringing out the more questionable potential of some health fashions, trends and movements of our time.  (Available for free download)

Artificial Epidemics
Published for e-readers by Now and Then Reader, February 2012
In the absence of appropriately discerning methods, the screening of large populations is bound to create problems.

Do No Harm: A Case in Point
Perspectives in Biology and Medicine 55 (2012): 291-98 
As the transcript of a charged meeting shows, the principle of avoiding harm is far from an inert doctrine without application to medicine.

Uninformed Consent: Mass Screening for Prostate Cancer
Bioethics 26 (2012): 143-48  
The full implications of the harm to which ill-informed men have subjected themselves during the PSA era are now becoming manifest.

What’s Wrong with Chemoprevention of Prostate Cancer?
American Journal of Bioethics 11 (2011): 21-25  
This article was posted as a “target” for commentaries, to which I reply in “Forfeited Health: A Reply to My Critics” (online only).

If not for the unintended consequences of PSA testing, would we even be discussing the preventive use of drugs associated with aggressive cancer?

To Feel What Others Feel: Two Episodes from 18th-Century Medicine
Medical Humanities 37 (2011): 34-37  
Neither a tree nor water could be magnetized, but the followers of Mesmerism might still be magnetized to one another.

The Power of Rhetoric: Two Healing Movements
Yale Journal of Biology and Medicine 84 (2011): 15-25  
By professing to be in touch with a power in the human body, both EMDR and Mesmerism acquire real power in the form of a following. 

A correct text of this article is available from the author.

From Medicine to Psychotherapy: The Placebo Effect
History of the Human Sciences 24 (2011): 95-107 
Even as the routine use of placebos in medical practice lost legitimacy, the placebo effect in the form of suggestion flourished in the practice of psychotherapy.

Lying About Placebos
Skeptic 16:2 (2011): 41-44
Can placebos survive unblinding?

How Did the PSA System Arise?
Journal of the Royal Society of Medicine 103 (2010): 309-12 
If you search Amazon for “cancer awareness,” you will find knee socks, pens, lanyards, stickers, but no books.

Imagination’s Trickery: The Discovery of the Placebo Effect
Journal of the Historical Society 10 (2010): 57-73
We can’t afford to overlook our vulnerability to medical delusions, one of the discoveries of the Enlightenment.

Reticence in Action: The Antisepsis Controversy
Journal of the Historical Society 9 (2009): 427-41 
While hospitals could be likened to fields of death, the thought that not chance but the surgeon was killing patients was not so readily admitted.

A Preventive Slippery Slope
Hastings Center Report, March-April 2009
When the PSA revolution got going twenty years ago, no one could have intended the ensuing epidemic of prostate cancer.

Do No Harm: How a Magic Bullet for Prostate Cancer Became a Medical Quandary
Ivan R. Dee, 2008
The finasteride controversy is important not only in itself and as an omen of the future conundrums of chemoprevention but as an instance and marker of the trend toward population-based medicine.  Reviewed in New England Journal of Medicine, June 5, 2008.  [Note: On Dec. 1, 2010 the FDA’s Oncologic Drugs Advisory Committee recommended against the use of finasteride and dutasteride for chemoprevention.  This book was cited in the course of discussion.] (Available on Amazon.com)

Seeds of Mortality: The Public and Private Worlds of Cancer
Ivan R. Dee, 2003.  Recipient of the 2004 PEN Award for the Art of the Essay. 

“One does not let go of this book easily”–the PEN judges.  Reviewed in New England Journal of Medicine, Oct. 30, 2003. (Available on Amazon.com)

The following is published only here:

“Superiority to Placebo” Prior to the 1962 Drug Amendments

In the United States the methodology of the well-controlled trial was shaped by reformers who thought little of drugs that did not distinguish themselves convincingly from placebo.

Trials and Errors: Blind Tests Before the Franklin Commission

The originality of the Franklin Commission’s work lay not in the blinding of test subjects but in raising what had been an improvisation into a method.

The following are online publications:

Unconscious Bias in Medicine: A Canard

Quillette, Sept. 5, 2023

Evidence that clinical decisions are driven by unconscious bias remains conspicuously lacking.

Comment on “The Art of Life and Death” by D. Fancourt and A. Steptoe, posted 24 June 2020; BMJ 2019;367:l6377.  Open access.
If engaging with art in a social setting is salutary because it relieves loneliness or reduces sitting, the actual content of the art matters as little as the content of a painting used to cover a hole in a wall.

Pressured Apologies, False Confessions, Witch Hunts

Skeptic 24.3 (2019): 46-51

The philosophy of tolerance rests on the principle that belief can’t be coerced. The philosophy and practice of intolerance draw strength from daily demonstrations that belief can be coerced, provided that the pressure is great enough and the enforced ideals sufficiently compelling.

Trigger Warnings and Mass Psychogenic Illness
Published on Quillette.com, Nov. 2, 2018 
Much as illness raced through a Tennessee high school not as a result of a toxic exposure but because those affected got swept up in a frenzy of imitation, demands for trigger warnings raced from coast to coast in recent years in a kind of epidemic manner.

When “Believe the Victim” Backfires
Published on Quillette.com, Oct. 6, 2018

It’s a measure of Krakauer’s antipathy to what was once called the liberal tradition that he specifically and repeatedly endorses rules requiring the police not just to handle allegations of sexual assault with due sensitivity, but to believe each and every allegation as soon as they learn of it.

Stimulants: The Long View
Published as a Mad in America blog, Oct. 3, 2017
When ADHD crusaders use phrasing like “a preference for the long-term over the short-term outcomes of behavior,” their words resonate precisely because, like the body of a violin, they are hollow.

Psychoanalyst, Show Some Modesty
Published as a Mad in America blog, Aug. 5, 2017 
Psychoanalysts may claim the right to judge public figures, but in the United States the authority of psychoanalysis suffered a collapse decades ago from which it never recovered.

Preventing the Risks of Prostate Cancer Screening
Bioethics Forum, April 7, 2009
The more questionable mass screening for prostate cancer looks–and in the light of recent studies its benefits look dubious indeed–the better appears finasteride.

Science in Wonderland: A Case in Point
Published Nov. 25, 2008 on Butterfliesandwheels.com, a website devoted to “fighting fashionable nonsense”
Prevention is so strongly associated with the utopian tradition, and utopian notions continue to exert such attraction, that even medical research may find itself drawn to utopianism by a kind of gravitational pull.

Investment in the Placebo Effect
Published August 3, 2008 on Butterfliesandwheels.com
Psychotherapy is a playground of placebo effects.