UPDATED: March 3, 2025
Welcome to the Healthy Living Is Good Medicine Newsletter, a totally free, health education publication covering a wide variety of topics with original articles intended to help people lead healthier and more fulfilling lives.
My Guiding Principle
The health profession’s universal precept, “First, do no harm,” is the foundational principle of medical ethics. One must always weigh the potential harms of a preventive intervention, medical treatment, or surgical procedure against its potential benefits. Avoiding harm needs to figure prominently in the decision-making processes of both doctors and their patients.
But what if a profit-driven healthcare system is inherently harmful, because it prioritizes corporate wealth over patient health? The basic formula for this system’s success involves extracting the most money possible from patients, while exploiting the good intentions of their healthcare providers. This has resulted in widespread harms, such as denying patients necessary medical care, and inflicting moral injuries on their providers:
Weighing the Evidence
If the totality of the evidence currently available is insufficient to reach a sound therapeutic decision, a physician might want to adopt a watch-and-wait approach, known as applying “the tincture of time.” In other words, when in doubt, do nothing!
This precautionary principle emphasizes preventing harm in the face of uncertain risks or the absence of conclusive scientific evidence regarding efficacy and safety. It advocates for erring on the side of caution in order to protect the public’s health and minimize potential harms to the patient.
The problem is that patients want solutions, and they want them now. At the same time, doctors want to be helpful and offer their patients something, rather than send them home empty-handed and tell them to come back in a few days if they aren’t feeling better. The expectations are amplified by clever pharmaceutical industry marketing strategies that imply there’s a cure for every ailment.
The standards of medical practice argue against hastily employing treatments that come with risks of serious adverse effects. Additional laboratory tests and imaging studies may be necessary to narrow down the differential diagnosis. In most situations, time is on the side of the clinician, but in a true medical or surgical emergency, delaying a risky treatment could mean flirting with disaster.
Decision-making becomes even more complicated when the studies of a specific treatment's outcomes have produced contradictory results. One would still seek to minimize risks, but there would be a lot more uncertainty about how to best go about doing that. Fortunately, when it comes to weighing potential benefits against potential harms, vaccines in general are overwhelmingly beneficial. The pseudoscientific, alarmist arguments of anti-vaccine conspiracy theorists can be summarily dismissed.
Doctors want to avoid iatrogenic illnesses and other medical complications caused by their actions. Medical errors are, unfortunately, not uncommon, and can be a major cause of injury and death, according to some studies. It is important for patients to recognize the significant challenges that can accompany standard medical and surgical care, and understand the risks versus benefits ratios that they may be facing:
Risk Tolerance
Some people are adrenaline junkies and love taking risks and living dangerously. That's not me. Although I've enjoyed participating in a few high-risk sports, I was aware of their inherent dangers, analyzed their risks, and did everything I could to minimize them. Thanks to a little extra luck, I'm still here to tell the tale. The flip side to my adventurousness is that in addition to keeping up-to-date with my COVID-19 vaccinations, I still wear an N95 mask in indoor public spaces, which I consider to be a minimal inconvenience in exchange for mitigating the risks.
It is a sad fact that our for-profit healthcare system provides financial incentives for risky medical and surgical procedures. The general rule seems to be that more aggressive interventions receive higher insurance reimbursements. For example, the overuse of coronary artery stents puts hundreds of thousands of patients in harm’s way, when there are less invasive (and less lucrative) alternatives. Private health insurance typically pays more than $20,000 per stent procedure.
An indelible lesson from one of my surgical rotations was that in a certain percentage of patients diagnosed with acute appendicitis, a surgeon will remove an appendix that is totally normal. There will be another percentage in which an appendix has already burst. An appendectomy carries less risk than an infected appendix spilling bacteria into the abdominal cavity, so erring on side of caution means operating unnecessarily in a certain number of cases.
A competent and ethical surgeon will strive for a 10-20 percent negative appendectomy rate. Hopefully, that's the surgeon you would get if you show up in the emergency department with right lower quadrant pain. Rates that fall above that range indicate that a surgeon is too eager to cut, and rates that are lower suggest that they are putting patients at greater risk for peritonitis and septic shock.
Questioning Proposed Treatments
The road to patient harm is paved with click-bait headlines based upon provisional conclusions from observational studies. When they are later refuted by negative clinical trials, they will receive scant attention by the media. People don’t show much in interest in what doesn’t work, but they sure get excited about something new that seems to.
Added to that, there’s a barrage of direct-to-consumer drug advertising (“Ask your doctor…”) on TV and in other media. The risks and adverse effects are presented, but you’ll miss them if you’re not paying close attention. There’s an amazing difference in what you’ll learn from a TV drug ad if you close your eyes and just focus on the audio.
The doctor you’re supposed to ask if the drug is right for you has their own set of obstacles to overcome. Patient pressure to try something they saw on TV, unfamiliarity with the scientific literature, personal biases, and the time constraints of office visits can become a formula for therapeutic missteps. That’s why patients need to educate themselves about their health challenges and play an active role in any decision-making.
The list of ineffective or harmful medical therapies, along with myriad bogus treatments pushed by quacks, is quite long, yet more are continually being added. Please be skeptical of non-prescription treatments extolled by your Facebook friends, TikTok influencers, or suggested by your chiropractor, naturopath, acupuncturist, or massage therapist. When there’s a choice, give a nod to prescription medications that have a long record of efficacy and safety, especially when there are less expensive generic versions available.
Disregard patient testimonials, and those from sell-out doctors. Instead, seek the opinions of bonafide medical experts in their respective fields. Then, consider getting a second opinion from another physician who is equally qualified. It can be quite unsettling when two competent specialists, presented with the same patient data, can differ in their opinions about the best course of treatment. It is therefore up to patients to weigh the pros and cons of each, and decide what seems best for them.
Burden of Proof
Let's not confuse legal terminology with medical and scientific jargon. Technically speaking, "proof" is a mathematical concept. Legal proof for something that's alleged to be true, is different, but is clearly defined by the law. Science offers conditional validation, rather than absolute proof. We can't prove that an hypothesis is true, but we can subject it to experiments that attempt to falsify it.
Probable cause is a legal standard that means a reasonable person would believe that a crime has been, is being, or is about to be committed. It is an absolute requirement under the Fourth Amendment to the U.S. Constitution that must be met before law enforcement officers can search a location, obtain a search warrant, or make an arrest.
Preponderance of the evidence is the legal burden of proof in most civil cases. It means that each element of a claim must be found more likely to be true than not. Science does not accept such a lax standard, but sometimes medical judgments will have to rely upon it, when that's the best evidence available.
Beyond a reasonable doubt is a guiding principle of the U.S. criminal justice system. Prosecutions must begin with a presumption of innocence. The prosecution must prove someone's guilt by offering enough evidence to erase a reasonable person's doubts about it. An American legal doctrine, proposed in 1769 by William Blackstone, states that it is better for 10 guilty people to go free than to wrongfully convict an innocent person. This moral rationale for protecting the innocent dates back to Roman times.
The law does not require absolute certainty to reach a verdict. Conclusions in science are never based upon complete certainty either. Science only provides the probable degree to which an evidence-based conclusion could be accurate. Those conclusions are always subject to invalidation by new data. Study results are typically expressed in terms of the confidence that an outcome isn't due to chance alone.
In medical research, the best evidence for causal relationships between an intervention or exposure and the outcome is derived from randomized, controlled trials (RCTs). Typically, participants in an RCT are randomly selected to be either in a treatment group or a control group that gets a placebo. When the study is double-blinded, neither the researchers nor the subjects will know who got the placebo until the study is concluded.
An RCT's data is then analyzed, discussed, and interpreted. A reputable study will discuss its possible sources of error and disclose the researchers' potential conflicts of interest. Its conclusions will be couched in a specific degree of certainty, which is never 100 percent. The authors will typically present numerical ranges around average values, known as the 95 percent confidence interval. The narrower the range, the more confidence one can have in the study's results not being due to chance.
For the conclusions from an RCT to be more convincing, the study will need to be independently replicated and reach similar conclusions. In practice, this rarely occurs because research grants usually fund original studies. In any case, most medical studies are not RCTs. Rather, they are observational studies, either looking back in time, or waiting to see what the future outcome of an intervention or exposure will be for a particular population. Such studies are weakened by their inability to control confounding variables.
Preventive Medicine and Risk Management
When it comes to preventive medicine, it is difficult to find convincing scientific evidence supporting some lifestyle interventions. The health impacts of treatments, interventions, and environmental exposures may be cumulative, or take a long time to appear in human subjects. Since observational studies will never be able to establish causal relationships, physicians must often make patient recommendations based upon a preponderance of the best currently available scientific evidence.
Let's not ignore the fact that much of the so-called "research" published in "junk journals" does not adhere to strict scientific criteria. Most doctors don't have enough time to keep up with the latest research, and it may be necessary to take a deep dive into the medical literature to separate the wheat from the chaff. Here’s a primer on how to make sense of a study:
That could be impractical for busy practicing physicians who are not also scientists. Consequently, doctors must do the best they can. while facing a certain amount of uncertainty. When in doubt, it's generally better for physicians to err on the side of caution. Taking a more conservative (risk minimizing) approach when making medical decisions requires sound clinical judgment and a consideration of the individual patient's needs. However, this isn’t always appropriate in emergency care settings, where unnecessary interventions could harm patients, strain resources, and drive up costs.
When a doctor's good-faith advice later turns out to be incorrect, as long as it has not critically delayed appropriate treatment, it should not have produced any significant harms. However, despite our best intentions, that's not always the case. We certainly aren't able to predict someone's future, and we can't insist that they heed our best yet fallible advice.
We can only inform our patients about what we know regarding the potential risks and benefits of various courses of action. If statistical probabilities are available, we can share them, while pointing out that statistics apply only to populations, not individuals. Once fully informed, it is then up to the patient to make decisions about their healthcare. Hopefully, good information provided by their doctors will lead to good decisions.
However, some patients may not want to make those decisions. Many patients will be swayed by their emotions. How can anyone still reeling from a cancer diagnosis rationally decide to undergo a difficult course of post-operative chemotherapy that carries a risk of permanent neurological or cardiac damage? When there's only a five percent chance that their type of cancer will recur following surgery without subsequent treatment, how will that impact their decision? Sadly, I have had a few patients who declined chemo because they thought the odds were greatly in their favor. They gambled, and as it turned out, they were among the five-percenters.
Moral of the story: If you want to increase your chance of survival following a life-threatening cancer diagnosis, do everything you can to push the odds of a cure toward 100 percent, even if it means risking serious side-effects from the "standard-of-care" treatments. Case in point: Diagnosed with pancreatic cancer, Apple Computer's co-founder, Steve Jobs, “trusted his intuition” rather than his doctor's advice, and sought alternative treatments. That allowed his cancer to advance until it became incurable, and fatal. I hope his doctor told him that delaying appropriate medical treatment would be crazy.
Chicken Soup for Colds
When it comes to treating symptoms of the common cold, there may not be anything that’s much better than chicken soup. According to one study, its slight anti-inflammatory effect could result in symptom relief. Even if only evokes a placebo effect, recommending homemade chicken soup for a common cold is far less harmful than prescribing antibiotics that can adversely impact the gut microbiome.
Many of the products found on drugstore shelves were grandfathered in by the FDA more than 50 years ago. Over-the-counter (OTC) drug manufacturers have been pushing a plethora of products using the same old ingredients, without having to prove their efficacy. New requirements for OTC drugs are much more stringent. In September, 2023, the FDA’s advisors concluded that the common nasal decongestant, phenylephrine, was ineffective, but the FDA cannot force its removal from the market.
One of the biggest mistakes that doctors can make is giving in to patient pressure and prescribing antibiotics for upper respiratory tract infections caused by a virus. Doctors who don't do what their patients want or expect risk receiving low ratings on doctor-scoring websites. The inappropriate prescribing of antibiotics contributes to the emergence of microbes that are resistant to multiple drugs. As a result, infectious organisms that are difficult or impossible to treat now present a global health threat.
Pesticide Residue Risks
There is a huge problem when it comes to studying the human health effects of pesticide, herbicide, and fungicide residues in people's foods. It would be unethical (and likely illegal) to perform an RCT in which some of the subjects are given known amounts of a pesticide, while the control group is not. Consequently, the estimated safe limits for chemicals used in agricultural production are based upon animal studies.
A Dietary Risk Index (DRI) is derived from detailed analyses of pesticide residue data, usage trends, and possible health risks. The DRI value for a pesticide is the dietary intake of that pesticide from a single serving of food, divided by the pesticide’s acceptable daily intake as established by the U.S. Environmental Protection Agency (EPA).
The DRI takes into account the average annual residue concentrations, and the residue levels found in individual food samples. DRI values can be aggregated over multiple pesticides in single food items, and for individual pesticides in multiple foods. According to the EPA’s website, under the Food Quality Protection Act “EPA evaluates new and existing pesticides to ensure that they can be used with a reasonable certainty of no harm to infants and children as well as adults.” It seems the EPA presumes “innocence” when the pesticide residue limits are actually followed by growers. The burden of proof for any harms is then left up to others.
The DRI study concluded that some kinds of organically grown produce contain far lower levels of agricultural chemicals than their conventionally grown counterparts, and that the best way to substantially reduce potential dietary risks is to identify high-risk fruits and vegetables and farm them organically. It is expected that the DRI will facilitate higher quality studies about the human health impacts of pesticide residues.
Due to public health concerns, substantial reductions in pesticide residue risks have resulted from the replacement of some organophosphate (OP) insecticides with neonicotinoids, while other OPs are still in use but under EPA investigation. The long-term effects on human health by neonicotinoids is still unclear, but their environmental impact is not. They are harming beneficial insects including pollinators, as well as aquatic invertebrates.
While it seems desirable to reduce agriculture's overall reliance on pesticides, herbicides, and fungicides, especially those that pose a higher health risk, that is unlikely to ever occur. Identifying the worst offenders might be a more effective strategy. Despite a claimed low human toxicity of the herbicide glyphosate (Roundup™, etc.), there is abundant evidence suggesting that glyphosate may be a cause of non-Hodgkin lymphoma. For a deep dive into glyphosate and its potential risks, see:
The issue with GMO crops is not their manipulated DNA, but rather the fact that they have been genetically engineered to withstand the application of chemicals such as glyphosate, and are therefore more likely to contain significant amounts of herbicide residues. Don’t let GMO shills with a toxic hidden agenda gaslight your legitimate health concerns about agricultural chemicals in your food and drinking water:
Pesticide Economics and Politics
According to the the United Nations' Food and Agricultural Organization's report, U.S. agribusiness is the world's largest user of pesticides. Despite being linked to significant adverse health effects, the U.S. allows the production and export of domestically banned pesticides, something one might expect from a ruthlessly capitalistic system that consistently puts corporate profits ahead of human health and welfare.
Because of the corrupting influence of corporate "big money" upon the American political system, and its trickle-down effects upon government agencies, health warnings and consumer alerts tend to lag behind the research and scientific consensus. Think about how long it took for a U.S. Surgeon General's warning label to be required on cigarette packages, and what is still lacking in the labels that appear on alcoholic beverages.
A self-proclaimed “expert” on Substack has been denigrating organizations ostensibly committed to food safety, such as Consumer Reports (CR) and the Environmental Working Group (EWG). Without offering evidence, she claims that both the CR and the EWG are biased by donations they get from the organic food industry. She goes on to dismiss people's concerns about chemical residues in their food supply, claiming that there is no credible scientific evidence regarding health risks. However, "Absence of evidence is not evidence of absence." ~ Carl Sagan
More to the point, this toxic individual disparages anyone who takes issue with the industrially produced chemicals found in their food and drinking water, accusing them of being "anti-science" and having a psychiatric condition called "chemophobia," an irrational fear of chemicals. She is using that pejorative term to disparage anyone who would rather not be consuming those chemicals, and anyone who proposes safer alternatives.
The reality is that government agencies don’t always get it right. Neither do ivory tower scientists and the peer-reviewed journals in which they publish. We know that the FDA and USDA are lobbied by the food, drug, and agriculture industries, and don’t always heed their own scientists and outside advisors. It is therefore perfectly rational to be concerned about non-food substances ending up in the foods that we eat.
Consumer Reports publishes a comprehensive review of pesticides in food, based on seven years of data from the U.S. Department of Agriculture (USDA), which annually tests for pesticide residues in selected conventional and organic produce, both domestically grown and imported. The EWG ranks the pesticide contamination of common fruits and vegetables after compiling the most recent data for the thousands of samples collected by the USDA. Neither organization does their own testing.
Of course, we don't have “gold standard” RCTs to provide convincing evidence for the causal relationship between exposure to agricultural chemical residues in food and adverse health outcomes. The observational studies that we do have are, by their very nature, unable to establish causality. At best they can identify statistical associations. On the other hand, a modicum of common sense tells us that no amount of pesticides can be truly good for us. So, once again, prudence would dictate erring on the side of caution.
There is no widespread scientific consensus about “safe” pesticide residue levels. The European Union's maximum allowable levels are generally lower than those set by U.S. agencies. Due to its precautionary approach, the European Food Safety Authority has a more rigorous approval process, requiring extensive data on human safety and environmental impacts, and applies more stringent risk criteria. It also has a better enforcement system to ensure compliance with its maximum allowable residue levels. However, according to a recent European Environment Agency briefing, pesticide pollution still poses significant risks to people’s health and the environment.
When to Buy Organic
Just because something is “natural” doesn't mean that it is good for our health. The “Death Cap” mushroom is naturally 100 percent organic, but even a little bite can kill you. Raw foods of all kinds present a much higher risk for food-borne illnesses than the cooked versions. Imported organic frozen strawberries have caused outbreaks of hepatitis A.
A pesticide residue burden score has been developed to quantify human exposures, but exactly how those scores relate to health impacts remains unclear. However, when three independent sources found that conventionally farmed strawberries have the highest level of pesticide contamination of all the fruits and vegetables studied, that's makes me want to grow my own, or buy fresh, organic strawberries from local growers.
The pesticide scores from this study are presented below. A score of 3 is the lowest, and 9 the highest level of contamination for conventionally grown produce. I'm not suggesting that you rely solely on these scores. Also consult the CR pesticide report and the EWG shoppers' guide before you decide on what to buy.
Pesticide Residue Burden Scores
Level 3: Onions, orange juice, frozen sweet corn.
Level 4: Bananas, grapefruit, peaches, tomatoes.
Level 5: Beans, cauliflower, sweet potatoes, watermelon.
Level 6: Broccoli, cantaloupe, oranges, pears, raisins, summer squash.
Level 7: Applesauce, apples, carrots, cucumbers, lettuce, plums.
Level 8: Grapes, collard greens, kale, spinach, sweet bell peppers.
Level 9: Strawberries.
Keep in mind that certification with the USDA Organic Seal still allows the use of a number of synthetic substances in organic crop production, along with chemicals that occur in nature. While pesticides aren’t totally prohibited, they are markedly restricted. Farmers are allowed to use them only when all other organic practices can’t adequately address their problem.
So, just because something is labeled organic doesn’t mean it is totally free of potentially harmful chemicals, and I don’t place much trust in large-scale organic farming operations. I’m even more suspicious about allegedly organic produce that’s imported. When all is said and done, it may be best to grow your own high-risk fruits and vegetables, get them from a community garden, or buy them fresh at local farmers markets and farm-stands.
The underlying science regarding the chemical contamination of foods, and the health risks that they might pose, clearly isn't perfect, but what little information we do have is the best we have to go on. Can eating lots of pesticide-laced strawberries be harmful? The answer is a definite “maybe.” But who wants to be the guinea pig in that experiment? A recent review has highlighted the potential consequences of pesticide exposure from disrupting the gut microbiome.
I’m certainly no “medical expert,” but I do try to communicate the best health information that I can gather from what appear to be reliable sources, while carefully navigating my way through a profusion of misinformation. Given the ongoing uncertainty about glyphosate, I’d still rather be safe than sorry, and avoid ingesting it when that’s both possible and practical.
It might be preferable to make a Type 1 Error (false positive conclusion) than a Type 2 Error (false negative conclusion), but both error types should be avoided. Wasting resources trying to protect oneself from non-existent dangers also come with the risk of developing maladaptive behaviors.
Contrast those consequences with wrongly concluding that something is benign, and not taking adequate precautions. In certain situations, tending toward Type 1 Errors could be advantageous, provided the cost of missing a real threat is significantly higher than the cost of a false alarm.
Individuals vary greatly in their risk tolerance or aversion, as well as in their ability to afford and employ potential mitigation measures. People will need to evaluate the available data and decide for themselves if there are some fruits and vegetables that are worth buying organic. I hope that whatever you decide, you'll favor choices that will first, do no harm.
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