Journal of Addictive Behaviors,Therapy & RehabilitationISSN: 2324-9005

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Review Article, J Addict Behav Ther Rehabil Vol: 5 Issue: 4

Sophisms to Sustain Disulfirams Efficacy

Zullino D*, Rothen S, Calzada G and Thorens G
Division of Addictology, University Hospitals of Geneva, Switzerland
Corresponding author : Zullino D
Head of the Division, Addictology Service, University Hospitals of Geneva, Grand Pre 70C, 1202 Geneva, Switzerland
Tel: +41 (0)22 372 55 60
E-mail: [email protected]
Received: October 06, 2016 Accepted: November 08, 2016 Published: November 15, 2016
Citation: Zullino D, Rothen S, Calzada G, Thorens G (2016) Sophisms to Sustain Disulfiram’s Efficacy. J Addict Behav Ther Rehabil 5:4. doi: 10.4172/2324-9005.1000157

Abstract

Despite the absence of adequate scientific evidence, disulfiram has been prescribed for decades and is still largely advocated. As the arguments sustaining its use cannot be evidence based, they have to be founded on other properties in order to be effective. The present paper reviews different forms of fallacies used to sustain disulfiram’s efficacy. We formulate the hypothesis that the frequency of consented use of fallacious arguments (or even sophisms) within an otherwise supposedly evidence based discipline may be indicative of (a) a scientifically immature discipline, and/or (b) a moralistically intermingled discipline. Inversely, the progressive decrease of sophisms should then be suggestive of scientific maturation.

Keywords: Disulfiram; Alcohol use disorder; Scientific method; Efficacy;Pharmacotherapy

Keywords

Disulfiram; Alcohol use disorder; Scientific method; Efficacy; Pharmacotherapy

Introduction

Disulfiram was introduced as a potential treatment for alcohol use disorders (AUD) in the 1950’. Since the nineteenth century, it had been used to accelerate the production of rubber. Rubber workers exposed to disulfiram were observed in 1937 to develop unpleasant physical symptoms after drinking alcohol, and many of them subsequently decided to remain abstinent [1]. Hence was formulated the hypothesis of disulfiram as a therapeutic drug against alcohol addiction.
Despite the absence of adequate scientific evidence (i.e. suitable randomized placebo-controlled double-blind studies), disulfiram has now been prescribed for several decades in many countries. E.g., 25% of US patients with alcohol use disorder receiving a pharmacological treatment were prescribed disulfiram in 2007 [2].
The randomized trials comparing the efficacy of disulfiram against placebo showed no differences in recovery time of alcohol consumption or total abstinence. E.g. the most recently published multicenter randomized placebo-controlled trial [3] concluded “Supervised oral disulfiram use followed by intervention via letters seems to be ineffective for increasing abstinence”’.
While professionals in the addiction field may acknowledge the lack of evidence and even the subsequent rationality not to prescribe disulfiram any more, they may still (and in disagreement to their acknowledgment) believe that disulfiram may be useful, at least for some patients [4].
Influential guidelines regularly mention the lack of evidence for disulfiram’s efficacy. The Practice Guideline for the Treatment of Patients With Substance Use Disorders, Second Edition of the American Psychiatric Association [5] e.g. states: “Without adjunctive psychotherapy, the utility of disulfiram may be limited” and “Controlled trials have not demonstrated any advantage of disulfiram over placebo in achieving total abstinence, delaying relapse, or improving employment status or social stability ...”. The Guidelines for Biological Treatment of Substance Use and Related Disorders of the World Federation of Societies of Biological Psychiatry, report [6]: “compelling evidence that disulfiram increases abstinence rates is lacking”.
Beyond the conclusion of a lack of evidence for disulfiram’s efficacy, we have recently discussed the conceptual problems when conceiving disulfiram as a therapeutic agent, be it considered a pharmacological and/or psychological agent [7,8].

The Rational to Use Sophisms

The fact, that disulfiram’s use is not supported by scientific evidence and the observation that it nevertheless is largely advocated and used, is probably one of the rare persisting abnormalities in an epoch of evidence based medical practice. This observation would be less odd in case of lacking or just preliminary evidence, as medical practice cannot always wait conclusive evidence to be endorsed. What is peculiar in the case of disulfiram’s prescription is its persistence against evidence.
Hence arise two questions: (1) Why is this possible (this will be discussed in the conclusions), and (2) how can it be supported, i.e. by what type of arguments.

Arguments

An argument can be defined as an attempt to persuade someone of something by giving reasons to accept a given conclusion (http:// www.criticalthinkeracademy.com). With regard to the present specific topic, an argument in favor of disulfiram’s efficacy would be an attempt to persuade an opponent of this thesis by giving reasons to accept the assertion of disulfiram’s efficacy.
Formally, an argument is a set of statements or propositions (which can be true or false, but not both). One of the claims forms the conclusion, the remaining are termed premises. The premises are intended to offer reasons to believe or accept the conclusion. A belief in this context will be a psychological state in which a person considers a proposition or premise to be true.
An argument is made by an arguer (hereafter called proponent) to an opponent. The opponent is conceived to be opposed at first to a specific claim, and to accept/believe subsequently the claim as a conclusion of a successful argument. We will use hereafter the term proponent for the arguer who sustains the claim that disulfiram is efficacious for treating alcohol addiction (and therefore should be used), and will call opponent the person who does contest disulfiram’s efficacy and/or the rationality of its use.
While the goal of an argument is to persuade, the goal of logic and argumentation is additionally to persuade for good reasons. In this sense, a good argument would give good reasons to believe the conclusion.

Fallacies and Sophisms

Fallacies are bad arguments, and they are bad arguments either because they have weak logic, or because they rely on a false premise, or they violate some other basic principle of argumentation (http://www. criticalthinkeracademy.com). A fallacy is thus constituted by a type of reasoning based on an argument with a flawed logical structure. However, a fallacy is not just a bad argument, but also an argument which in fact may appear to be quite valid, but is in reality flawed.
According to the Oxford dictionary (http://oxforddictionaries. com/definition/english/sophism?q=sophism), a sophism is “a clever but false argument, especially one used deliberately to deceive”. Sophisms are thus intentionally used fallacies. They are an attempt to persuade opponents that the specific conclusion is true, by means other than by proposing relevant evidence. Sophistry thus is a matter of intention.

Inductive Fallacies

Inductive reasoning consists of inferring from the characteristics of a sample to the properties of population from which it was drawn. Inductive reasoning is the practice of making general conclusions from specific phenomena.
Inductive arguments are thus arguments where the conclusion is merely based on probability, not necessity (http://www. criticalthinkeracademy.com). No inductive inference can thus be perfect. Even though all premises are true, the conclusion might nevertheless be false. Nonetheless, a good inductive inference provides a reason to believe that the conclusion is possibly accurate.
Actually, inductive reasoning is risky reasoning, as it is fallible reasoning, where one moves from acknowledged facts about observable phenomena, to a hypothesis or a conclusion about the world beyond the observable facts. Inductive fallacies are thus arguments where a conclusion is reached from weak premises. They consist in the inaccurate use of inductive reasoning in case of insufficient samples to sustain a claim.
Inductive fallacies should usually be prevented by the Evidence Based Medicine, which is among others grounded on Karl Poppers hypothetico-deductive method [9]. Inductive fallacies are accordingly one of the main targets of critics in the framework of peer review. Hasty Generalization consists in the inductive generalization about a population based on a sample which is to small to support it. In the Unrepresentative Sample fallacy the sample used in an inductive inference is relevantly different and thus unrepresentative from the population as a whole. Using the Fallacy of Exclusion one excludes important evidence from consideration, which would undermine the inductive argument thus violating the “principle of total evidence” that requires that all relevant information be included. The Incomplete Evidence, also called Suppressed Evidence or Cherry Picking consists of focussing on individual observations or data confirm a particular claim, while ignoring significant cases or data that may contradict that position.

The Red Herring Fallacies

The large group of so-called red herring fallacies is probably the most frequently observed fallacy in the context of scientific argumentations. The maneuver consists in distracting the opponent from following the track of the original argument. This can be done by multiple means:
Introducing a new and different argument which raises a different issue, e.g. insisting on an indicator of the claimed conclusion instead of direct evidences
Making simply an irrelevant comment that distracts from the main issue, e.g. talking about something interesting related to the issue which is, however, not undoubtedly correlated to the claimed conclusion
The name “red herring” has its origin in an old method of training dogs for fox hunting. The goal is to train the dogs not to be distracted from the fox’s trail by smell of smelly red herrings.
In order to work as a red herring, the new element (the red herring) should be distracting enough to motivate the opponent to follow this “new trail”. Analogously, the red herring fallacy actually occurs when the opponent is driven to “lose the original trail” and to “follow the smell of the red herring”, concluding something from this different issue. In fact, the proponent using a red herring sophism avoids engaging the original argument. The defense to this type of fallacy (or sophism) would simply consist in insisting on the “original track”, on the original argument.
These types of fallacies can also be called fallacies of relevance, as they make use of premises, which are logically irrelevant to the final conclusion.
Example: “My opponent has argued that evidence for disulfiram’s efficacy is lacking. But the most important question is rather how to structure disulfiram prescription, especially how to support compliance by significant others. This is where we need to focus our attention.”
In this example, the original issue was about disulfiram’s efficacy (as to be assessed by a RCT disulfiram vs. placebo). The response “side steps” that issue and introduces as new issue, the question of the efficacy of supervision by significant others on compliance.
Example: “I do not understand why you struggle against disulfiram. There are many more problematic drugs on the market. You should fight against the overuse of stimulants among children.”
Certainly, overuse of stimulants can be viewed as problematic, but that it is another issue. The question at hand is: “Is disulfiram efficacious?”
The red herring maneuver can appear in many different forms, some of which will be treated hereafter.
Fallacies of indicators
According to the Oxford dictionaries (http://www. oxforddictionaries.com) an indicator is “a thing that indicates the state or level of something”. Thus an indicator can be understood as a phenomenon (measure, observation etc.), which is in a certain correlation with another phenomenon that is itself the actual object of interest. An indicator is useful in case the observation/measurement of the actual object of interest is not suitable (impossible, to expensive, to slow, to complicated, less comprehensible etc.). Thus, to argue on the basis of an indicator (e.g. compliance) instead of the actual object of interest (e.g. efficacy of disulfiram) could be judicious if the indicator was a valid and reliable measure for the latter.
Appeal to authority
The appeal to authority (also called ad verecundiam) is perhaps the most classical form of indicator fallacy. It consists in considering an argument as good or bad, or a claim as true or false, because an authority says so. The authority can be a person, a book, a website, an institution etc. The justification for the inference rests primarily on the authority of the source. If it is true that it is more probable that an expert rather than layperson is right, this is not always reliably so. Until we do not know the reasons of the authority’s claim (available evidence, personal interest, vanity etc.), we still can doubt about the pertinence of entrusting it without querying the evidences. In using this sophism one thus attempts to exploit upon feelings of respect or familiarity with this authority (the red herring) in order to let forget the necessity of direct evidence for the claim.
Example 1: “During the last congress of addiction medicine, Professor X, a well known specialist, has said that disulfiram is efficacious. Thus, disulfiram is efficacious.”
Example 2: “Professor X, the well known specialist, prescribes regularly disulfiram. Thus, disulfiram should be prescribed.”
In the latter example the proponent, furthermore, confuses “is” (a descriptive statement) and “should be” (a normative statement).
Appeal to accomplishment
In this case, an assertion is deemed true or false based on the accomplishments of the proposer. It is thus a sub-form of the appeal to authority, as the latter is justified by the stated accomplishments
Example: “If I tell you, that disulfiram is efficacious in patients with alcohol addiction, you surely can believe me, I have treated during my career more than 1000 patients.”
Argumentum ad populum
This fallacy consists in using an appeal to popular assent. This is sometimes considered as a subcategory of the appeal to authority. It can come in different forms.
The bandwagon approach
Using this fallacy (also: appeal to widespread belief, appeal to the majority, appeal to the people, appeal to popular belief, appeal to popular practice) one affirms that, since the majority of people believes an argument or behaves in a certain way, the argument must be true or the behavior is justified.
Example 1: “Last year 85% of physicians have prescribed disulfiram at least once; all those colleagues can’t be wrong. Thus, disulfiram is efficacious.” (appeal to popular practice)
Example 2: “A recent survey among 1500 physicians has shown that 87% consider disulfiram an efficacious drug in the treatment of alcohol addiction. They surely can’t be all wrong.” (appeal to popular belief)
The argument is fallacious because the number of the persons believing in disulfiram’s efficacy is logically irrelevant to the truth or falseness of the assertion regarding its efficacy. This will even be the case if all living persons believe the false. E.g. the sun never turned around the earth, even during the period when the whole humanity thought so.
The elitist approach
While the bandwagon approach asserts that everybody or most believe a claim, the elitist approach states “all or most of a special class of people believe it”.
Example: “OK, junior physicians seem to use disulfiram rather seldom, but most of the experimented alcohol specialists use disulfiram. As a reasonable person, can you still maintain the claim of its inefficacy?”
The allegation is that those who fail to accept the truth of the proponent’s assertion are not a reasonable, and thus the opponent had best recognize that necessity.
Argumentum ad antiquitatem
This fallacy is also called argumentum ad traditionem. A proposal is claimed to be superior or better because it has a tradition and/or it has been in use since long time. When using this sophism, one asserts a premise to be true because people have always/for a long time believed it or done it.
Example 1: “Disulfiram has been used since many decades. Thus, it is efficacious.”
Example 2: “Disulfiram is the best known drug for this indication, thus …”
Example 3: “Hundreds of doctors have prescribed disulfiram since decennia. And now you honestly want to assert they weren’t right?”
The inverse (argumentum ad novitatem) is often observed as a marketing maneuver. However, it is not used with regard to disulfiram as the drug has now been used for several decades.
The historian’s fallacy
This fallacy occurs when assuming that a decision made in the past was based on the same evidences as those currently available, or was based with the same perspective.
Example: “If disulfiram has been registered for the use in alcohol addiction since many decades, there is a good reason … thus disulfiram should be used in this indication.”
Argumentum ad lazarum
Using this fallacy (also: appeal to poverty) one supports a conclusion is true because the arguer is poor.
Example: “Our company has one of the smallest marketing budgets. There must thus be another reason for disulfiram’s widespread use. It has to be its efficacy.”

Ad Hominem Fallacies

The ad hominem fallacy (also called: personal attack, poisoning the well) is a form of red herring that consists in attacking the opponent instead of the argument. It may consist e.g. in rejecting a claim or an argument by denouncing a dislikeable characteristic of the person. The argument is fallacious because the personality of the opponent is in fact irrelevant to the truth or erroneousness of the argument itself. The statement “There is no evidence for disulfiram’s efficacy, thus it should not be prescribed” will be true regardless if is stated by a child, a murder, a layperson, or a Nobel prize winner.
This fallacy may take different forms.
The abusive form
This may be considered the classical form of ad hominem. Instead of attacking an assertion, the argument attacks the person who made the assertion.
Example: “You are one of the most hated persons in your institution, you can’t be credible saying, that disulfiram is not efficacious”
This is a fallacy because even if it’s true that the opponent is hated, this is irrelevant to the goodness or badness of his arguments. There might be reasons to dispraise the person, but this is not a reason to reject the argument.
More typically, the sophism will take the following form:
Example: “You are a junior physician with poor experience in pharmacology and addiction treatment, thus your arguments against disulfiram’s efficacy are not credible.”
Again, the premises may be absolutely correct, however, they are irrelevant.
The guilt by association form
Instead of attacking an assertion, the author calls into attention the relationship between the person making the assertion and the person’s contexts, e.g. its association to other persons, institutions or groups who put the opponent into an unresolved conflict of interest.
Example: “You have been sponsored by a commercial competitor of the producer of disulfiram, thus your arguments against disulfiram’s efficacy are flawed.”
Example: “You are a member of a society sustaining mainly psychological interventions for alcohol addiction, thus your arguments against disulfiram’s efficacy are flawed.”
Accordingly, when using the guilt by association maneuver, one dismisses the premise by calling into question the motives of its proposer.
Appeal to hypocrisy
The appeal to hypocrisy (also: tu quoque, you too fallacy) is another type of ad hominem where the opponent’s position is rejected because he is somehow being inconsistent, that he “does not always have practiced what he preaches”.
Example: “You claim disulfiram to be inefficacious, but we know that you have yourself prescribed it to your patients.”
Thus again, a disadvantageous characteristic of the proponent is irrelevant to the goodness or badness of his arguments. The blame of hypocrisy might be justified, but that alone won’t change a valid argument into an invalid argument. Otherwise the person itself would become the argument.
Inflation of conflict
This sophism consists in disagreeing (possibly with good reasons) on a certain point, and disqualifying the opponent on this basis as not expert in the whole specific field of competence.
Example: “As you didn’t know the study which has found disulfiram to have less side effects than X, you are not expert in the field. Thus, your conclusion of disulfiram’s inefficiency is not credible. Thus, disulfiram is efficacious.”

Straw Man

The straw man fallacy may be considered a particular form of red herring fallacy. On one hand it is a form of fallacy of relevance. On the other hand, it can be contrasted to the “classical” red herring fallacies. While the red herring involves avoiding the original argument, the straw man maneuver involves distorting it, and then giving reasons for accepting the distorted argument.
Instead of trying to refute a proponent’s actual argument, the opponent engages a different argument, engaging thus a metaphoric straw man, i.e. a weaker (distorted) version of the proponent’s original argument, which in fact is irrelevant to the issue. It includes e.g. any attempt to support an argument by overstating, exaggerating, or over-simplifying the arguments of the opponent.
Engaging a straw man argument is like defeating a dummy-argument rather than engaging in the real matters of the debate.
Proponent: “You should prescribe disulfiram”
Opponent: “But current evidence does not sustain disulfiram’s efficacy in treating alcohol addiction.”
Proponent: “It’s clear from your arguments that you’re really advocating for controlled drinking. But recent data has shown that controlled drinking does not work for everybody. Many patients with alcohol addiction simply cannot handle the urgency to drink. Thus you should use disulfiram.”
While it surely may be true that not all persons with alcohol addiction can handle their urgencies to drink, this argument constitutes the straw man, being completely irrelevant with regard to the efficacy of disulfiram. The efficacy or inefficacy of disulfiram is independent from the question about potential controlled drinkers, even if there was a differential efficacy regarding these two groups of patients.

Appeal to Emotion

This class of fallacies contains among the most frequently observed. Actually many of the other red herring sophisms could be reinterpreted as appeal to emotion. E.g. an ad hominem could be thought of as an appeal to negative emotions towards the opponent, and accordingly to his argument.
Some of these sophisms are rather exceptional within the scientific context, as e.g. the appeal to fear, where an argument is made by increasing fear and prejudice towards the opposing side.
Appeal to flattery
The argument is made due to the use of flattery to gather support for a claim.
Example: “You are one of the most renowned expert in the field and an opinion maker. You surely will concur that disulfiram is efficacious”
Appeal to pity
The appeal to pity (also: argumentum ad misericordiam) is an attempt to induce pity to influence the opponent, a classical marketing technique used in face-to-face maneuvers. The opponent should thus be persuaded to agree by sympathy.
Example: “I am desperate, our sales are critically low in your region. In a near future I’ll risk to lose my job. Help me understand this indifference among your colleagues toward our product. Don’t you agree that there is something wrong, if doctors of the regions served by my colleague retailers prescribe it and at the same time almost nobody in our region?”
Appeal to ridicule
The argument of the opponent is presented in a way that makes it appear ridiculous.
Example: “Doctor X claims disulfiram to be inefficacious? Ladies and gentlemen, we have entered the third millennium now since many years, and doctor X still tries to combat modern medicine. That’s what I would call a modern Don Quichotte.
Argumentum ad consequentiam
In this fallacy (also: appeal to consequences, argument from adverse consequences), the conclusion is supported by a premise that asserts negative consequences from some course of action. It typically asserts that an argument must be false because the implications of it being true would create undesirable results. It can be considered as a subcategory of appeal to emotions in the sense that appealing to adverse consequences is intended to prompt emotions intended to persuade the opponent.
Example: “If disulfiram really was not efficacious, this would mean that doctors prescribed a useless and possibly toxic drug to thousands of patients and this during several decades. This really would be a grotesque. You can’t truly claim that.”
The argument is obviously illogical because truth and falsity are not contingent based upon how much one likes or dislikes the consequences of that truth.
Argumentum ad baculum
This fallacy (also: appeal to the stick, appeal to force, appeal to threat) is made through coercion or threats of force to or other unpleasant backlash to make the opponent accept a conclusion.
Example: „Our society has published guidelines stating that disulfiram is efficacious. If you maintain your assertion of disulfiram lacking efficacy, nothing hinders us to expel you from the society.”

Slippery Slope

The slippery slope fallacy (also: Camel’s Nose Fallacy) consists in asserting that a relatively small first step inevitably leads to a chain of related events culminating in some significant undesirable impact/ event, denoting that the first step therefore should not happen. It takes the form of a series of connected conditional claims, to the effect that if one assumes that A is true (or allows A to occur), then B will follow, and if B follows then C will follow, and if C follows then D will follow etc. One of the consequences (e.g. D) is feared.
Example: “At first you doubt on the efficacy of disulfiram, then on the efficacy of psychopharmacotherapy, then on the efficacy of medicine, and at the end you refuse to treat any patient.”
A slippery slope is an illegitimate use of the if-then operator. The fallacy consists in the fact that no logical proof is provided that the acceptance of the first step necessarily will lead to the catastrophic final outcome.

Reification

This fallacy is also called hypostatization. It consists in treating an abstraction as if it was concrete or a physical entity.
Example: “Disulfiram has the same effect as a constantly accompanying person who remembers the patient not to drink. If you assert being able to personally refrain the patient to drink once you are on his side, you cannot refuse the idea that disulfiram can.”

Non Causa Pro Causa

Non causa pro causa are fallacies not recognizing the following rule:
A cause C is the cause of an effect E if and only if:
Generally, if C occurs, then E will occur, and
Generally, if C does not occur, then E will not occur ether.

Post Hoc Ergo Propter Hoc

This fallacy (also: faulty cause/effect, coincidental correlation, correlation without causation) has the following structure: A occurred, then B occurred; thus, A caused B. It consists in believing that, because a phenomenon A has occurred before phenomenon B, B has been caused by A, without any evidence sustaining such a belief. While it can be the case that A causes B, it not necessarily does. This is a classic fallacy founding various superstitions.
Example: “The patient took disulfiram and then he never drank anymore. Thus, the effect of (taking) disulfiram is the cause of its new abstinence. Thus, disulfiram is an efficacious drug.”
Disulfiram could theoretically be a potential suspect for the cause, but the mere fact that disulfiram ingestion preceded a change in drinking behaviors does not yet conclusively rule out other causes. Again, this is “la raison d’être” of randomized controlled studies.
The regression fallacy
The so-called regression fallacy is a special case of the post hoc ergo propter hoc maneuver. It ascribes causes where none exist, failing to account for natural fluctuations.
Example: “As the manic episode of this patient waned, he could again be persuaded to take disulfiram. Some days later he was already able to go to a bar without any craving for alcohol. Thus disulfiram was efficacious.”
Joint effect
Another special case of post hoc ergo propter hoc is the joint effect. One thing is held to cause another when in fact both are the effect of a single underlying cause.
Example: “The patients stopped drinking because he took disulfiram.”
In fact, both may be the result of a third factor (motivation etc.).

Cum Hoc Ergo Propter Hoc

This fallacy (Literally: with this, therefore because of this) takes the following form: A and B happen at the same time, therefore A must be causing B to happen.”
Example: “When he knows, that he has taken his disulfiram, he does not drink.”
While this argument implies that the patient does not drink due to his fear of disulfiram’s effect (dissuasion, one of the claimed effect mechanisms), the coincidence could be due to the patient’s decision to change behavior, which prompts him (1) to take disulfiram and (2) not to drink.
Texas sharpshooter
This fallacy is committed when differences in data are ignored, but similarities are stressed out. It consists on the focus on a small subset of a larger data set. It may e.g. consist in using the same data to both construct and test a hypothesis.
Its name comes from a parable describing a Texan firing his gun at the side of a barn, then painting a target around the shots and claiming to be a sharpshooter.

Fallacies of Presumption

Fallacies of presumption occur when the premises already assume what they are supposed to prove. They include among others begging the question, complex question, and false dilemma.

The false Dilemma

When using this sophism (also: false dichotomy, fallacy of bifurcation, black-or-white fallacy, either-or fallacy, excluded middle) two alternative statements are held as if they were the only possible options, when in reality there is at least one more. Thus, it consists in giving the opponent two options, and requesting the rejection of one of them, forcing him to accept the remaining option. This becomes a fallacy when the options given don’t include all the real options. A false dilemma is thus an illegitimate use of the “or” operator.
Example 1: “Do you think that alcohol addicted patients deserve treatment or do you refuse them disulfiram?”
Example 2: “Do you prescribe disulfiram, or are you among those antiquated physicians who think that alcohol addiction is a moral fault and does not merit treatment?”
Argumentum ad ignorantiam
The argumentum ad ignorantiam (also: appeal to a lack of evidence) consists in appealing to a lack of information to prove a point. This represents a special case of the false dilemma, as it suggests that all propositions must either be known to be true or known to be false. It thus has the following general form: proposition A is not proved to be false, therefore A is true.
Example: “Because a true double-blind placebo-controlled study cannot be performed (as un-blinding can easily be done by study subjects), a lack of efficacy of disulfiram cannot really be corroborated … thus: disulfiram is efficacious.”
The fact that it cannot be (definitively) proved that disulfiram is not efficacious does not prove that it is. Nor would the fact that it cannot be proved that it is not efficacious (what however has been proved) prove that it isn’t.
The tactic involves a reversal of burden of proof (onus probandi). Within the framework of the scientific method, the burden of proof is usually considered to be on the person who formulates a hypothesis (i.e. who makes a claim), and not on those who question that hypothesis. Thus, the argumentum ad ignorantiam directly violates the principles of EBM.

Argumentum e Silentio

This is another sophism that tries to reverse the burden of proof. It consists in concluding on the absence of evidence, rather than the existence of evidence. While this sophism resembles the argumentum ad ignorantiam, it is not the lack of contradictory evidence, which is taken for supporting evidence, but the lack of evidence tout court.
Proponent: “I have patients who responded very well to disulfiram (abusive generalization), so give me any evidence of its inefficacy.”
Opponent: “We have discussed this before and I gave you all the necessary evidence. While you simply repeat your assertion based on single cases, I am bored to expose you again the scientific evidences.”
Proponent: “So finally you have to admit its efficacy.”
Refusal to share evidence is in itself no evidence for or against an argument. Silence is not a valid substitute for reason or evidence.
Another form: “As we do not have enough evidence, we should not precipitately reject disulfiram as inefficacious
As the FDA did not ask for new studies and maintains disulfiram on the list, the quantity and quality of evidence is sufficient to consider disulfiram efficient.”

Begging the Question

This fallacy is also called circularity or circular reasoning or petitio principi. An argument begs the question when assuming as true specifically what is at issue in the argument. Thus, the argument includes a premise, which asserts to be true what is asserted in the conclusion. The reasoning becomes circular as the conclusion corresponds to the premise and so on. Instead of drawing logical support from the premise, the conclusion will simple restate the premise, so that the argument includes nothing more than a repetition without offering any other reasons to believe it.
Example 1: “Since I’m not lying, it follows that I’m telling the truth.”
Example 2: “Physicians must have the right to choose the treatment for their patients. Thus, physicians should be free to prescribe disulfiram.”
The argument essentially involves restating the conclusion in different language.
While the wording of the two sentences is different, the single premise and the conclusion are asserting the same. This, however, does not form a valid argument. The issue is whether disulfiram treatment is scientifically justified for patients with the indication of alcohol addiction.
Thus, when using a begging the question sophism, the argument is flawed by assuming as true, something that in fact has to be argued for itself. Arguments that beg the question don’t propose any reasons to who didn’t already accept the conclusion. Thus, the final proof relies on unproven evidence set forth initially as the subject of debate.
Ignoratio elenchi
This fallacy (also: irrelevant conclusion, missing the point) occurs when adapting an argument purporting to establish a particular conclusion and directing it to prove a different conclusion. It specifically consist in using arguments that may in themselves be valid, but do not address the issue in question.
Example: “You will agree that patients should have a right to decide themselves about their treatment. Most of my patients choose disulfiram. Thus, it is my duty to prescribe it to them.”
Most, presumably, many will agree nowadays that patients should have a right to decide about their treatment. However, the question at hand concerns a particular treatment. The question really isn’t “Is it good to have patients decide about their treatment?” The question in fact is “Is this particular treatment actually a treatment, i.e. is there enough scientific evidence to reasonably consider it a treatment?” Only after having corroborated the hypothesis of disulfiram as an efficacious treatment, can the question of the patient’s choice been asked. Only then has he a real choice: between taking disulfiram and not taking it, and possibly between taking disulfiram or an alternative treatment.
Example: “You should support a larger prescription of disulfiram. We can’t continue to accept these high incidences of alcohol related liver cirrhosis.”
We may agree that the incidence of alcohol related liver cirrhosis may merit to be curbed down even though we can disagree that disulfiram should be prescribed.
Example: “In order to be used in a specific indication, therapeutic drugs should be tested in clinical trials. Disulfiram has been tested in clinical trials. Thus, disulfiram should be (or at least can be) used in the specific indication.”
The argument, that therapeutic drugs should be tested in clinical trials surely is valid, as it is not contested in the framework of EBM. The argument does however not address the question of efficacy of the treatment, but of its regulation.
Complex question
This fallacy (also: loaded question, plurium interrogationum) consists in phrasing a question or statement so to signify another unproven statement to be true without giving other evidence. This type of fallacy thus overlaps with begging the question, as it also presumes a specific answer to a previous, unspoken question. Thus, two otherwise unrelated points are conjoined and treated as a single proposition. The opponent is expected to accept or reject both together, when in fact one is acceptable while the other is not. A complex question is formally an illegitimate use of the “and” operator.
Example: “Don’t you think that we should support the rights of patients with an addictive behavior to receive efficacious treatments and to have free access to disulfiram.”

Other Rhetoric Maneuvers

Argumentum ad nauseam
The argumentum ad nauseam, or argument from repetition, consists simply in repeating an assertion extensively, until nobody cares to discuss it anymore. The proponent thus tries to support the apparent credibility of an argument simply by repeating the same thing over and over again.
Shotgun argumentation
The arguer offers such a large number of arguments for his position that the opponent can’t possibly respond to all of them. It may e.g. be used during a discussion by asking the opponent not to interrupt the proponent after asserting a claim and to wait until the end of his argumentarium.
The false compromise
This is a fallacy (also: argument to moderation, argumentum ad temperantiam, middle ground fallacy) where given two positions one assumes that there must exist a middle position that is the correct one.
Example: “As our opinions contrast, we could agree on a compromise, saying that disulfiram is not indicated in all but in some cases.”
The fallacy usually occurs when two sides of an argument are assumed to have equal value regardless of their respective merits.

Propositional Fallacies

Affirming the consequent
This fallacy has the general form: If A then B, B, therefore A.
Example: “If disulfiram is efficacious (if A), then patients should improve (then B). My patients improved (B), thus disulfiram is efficacious (therefore A).”
Of course, even though the premises are true, patients might improve for many other reasons.
Denying the antecedent
This fallacy takes the following form: If A then B; Not A, thus Not B
Example: “If disulfiram was prohibited (A), its prescription should be avoided (B); Disulfiram is not prohibited (Not A), thus its prescription should not be avoided (Not B)”
Obviously, it should also be avoided in case of other reasons, especially if its efficacy has not been corroborated by scientific evidence.

Syllogistic Fallacies

Among the different syllogistic fallacies (undistributed middle term, illicit major, illicit minor), only the first may be of interest related to disulfiram’s claimed efficacy.
Undistributed middle term
Two separate categories are said to be connected because they share a common property. This describes a specific type of error in deductive reasoning in which the minor premise and the major premise of a syllogism might or might not overlap.
A valid syllogism would be: “All dogs are mammals. All German shepherds are dogs. All German shepherds are mammals.” The middle term German shepherd fits in the categories of both dogs and mammals.
An invalid syllogism with an undistributed middle term would have the following form: “All dogs are mammals. All cats are mammals. All dogs are cats.” Here the middle term of dogs does not fit into the categories of both mammals and cats.
Example: “All efficacious treatments are registered. Disulfiram is registered. Thus disulfiram is efficacious.”

Reasons for the Frequent Use of Fallacious Arguments

Proponents of fallacious arguments may use them (and persist on them) either because they are incapable or because they are unwilling to accept their arguments to be fallacious.
The observation of a regular occurrence of fallacious arguments when claiming disulfiram’s efficacy begs the question about the reasons for this phenomenon in the specific field of addiction treatment. At least two hypotheses could be formulated.
Proto-scientific context of addiction medicine
The practice of addiction medicine happens often in a multidisciplinary environment that may be among others be influenced by non-medical disciplines, which are less rigorously evidence-based, and where inductive reasoning may be somewhat more endorsed. In more authority- than evidence based disciplines the rhetoric capacity of opinion-leaders may become a major factor in shaping decision-making. Thus, in such an environment the credibility of the proponent (and be it due to sophistic abilities) may eventually weight more than credibility of experimental data.
Within the same line of reasoning one could hypothesize that the relative poverty of well-validated pharmacological treatments may render addiction professionals more prone to be tempted by non-validated methods or even by methods that cannot be scientifically tested, and to justify post hoc their choice, which, in case of challenging evidence, can only be done by erroneous reasoning, be it knowingly (sophisms) or inadvertently (fallacies).
The moralistic perspective
While it has recently been claimed that modern addiction medicine has swept away previous moralistic positions, this may not always and completely be true. The still ongoing debate about the primacy of abstinence vs. harm reduction objectives may be just one illustration of moral value laden controversies within this field. The commercial name of disulfiram, Antabus® itself is indicative of a morally loaded concept: “against abuse”.
According to http://dictionary.reference.com/browse/abuse the noun abuse means among others wrong or improper use, harshly or coarsely insulting language, bad or improper treatment, a corrupt or improper practice or custom, rape or sexual assault. Thus, the term almost exclusively denotes moral values. At the most, the turn of phrase “improper use” could be also interpreted on the basis of pragmatic instead of moral values.
Punishment
Punishment can be defined as the authoritative imposition of something undesirable or unpleasant upon someone, in response to behavior an authority deems unacceptable or a violation of some norm (http://plato.stanford.edu/entries/legal-punishment/# PunCriSta).
Besides deterrence, rehabilitation, and incapacitation, a main justification for punishment is often retribution. Retribution can be considered as part of the definition of punishment itself, as none of the other justifications is a guaranteed outcome (with the exception of the capital punishment as a mean of incapacitation).
Retribution itself is usually justified on the basis of the conviction that the wrongdoer’s activity has given to him an undue benefit to the dismay of someone else. The goal of punishment will thus be to rebalance any unjust advantage gained by warranting that the wrongdoer suffers similarly. This would be somewhat a way of “getting even”, even if the punishment has no restorative benefits for the supposed victim (a person, the society etc.).
When thus envisaging alcohol use among patients as a moral fault, castigation may become a sound response, independently of any pragmatic reasoning, as it is habitually requested by evidence based medical practice. I.e. the punitive “treatment” has not to be efficacious in the sense of improving the patient wellbeing or functioning. If pure atonement is the objective, it may be largely be sufficient that it is efficacious inducing suffering.
Thus 3 categories of proponents of disulfiram may be conceptualized:
The Hippocratic proponent
He would endorse a Hippocratic model (primum nihil nocere) in the sense that the objective of his treatment would be formulated as an improvement of patient’s wellbeing, his quality of life. Moralistic values would expressly be disqualified as motives of his arguments. He would try to test a supposed treatment (disulfiram) regarding its efficacy related to these objectives (quality of life or at most abstinence as an intermediate step toward a better quality of life). In case of a lack of evidence in support of the treatment, he would reasonably refrain from supporting its use. These are in fact the basements of EBM. Fallacious arguments would be refuted by his peers (thus peer reviews), and he would accept to correct his flawed reasoning accordingly.
The moralistic proponent
He would endorse a moralistic model in the sense that the objective of his intervention would be formulated as the atonement in response of a moralistically improper behavior (drinking alcohol). He would, analogously to the Hippocratic proponent, try to test his intervention (disulfiram as a mean of castigation) regarding its efficacy related to these objectives (suffering). His method could in correspondence be called evidence-based castigation (EBC).
The ambitendent proponent
This type of proponent would be characterized by contradicting attitudinal drives. On one side he wants to endorse the Hippocratic model and on the other side he is (unwittingly) driven by moralistic values. If both objectives (the Hippocratic and the moralistic) had been achievable, i.e. if disulfiram would have been efficacious in a therapeutic way and as a punishment, the ambitendency would not be an issue. It would be sufficient to argue for the therapeutic efficacy of disulfiram to have it applied simultaneously as a punishment. Thus, the prescribing physician could be therapeutic when concurrently remaining moralistic.
As the therapeutic efficacy of disulfiram cannot be scientifically sustained, only two responses are possible to the ambitendent proponent: (1) he becomes a moralistic proponent; (2) he remains an ambitendent proponent trying to accommodate with the dilemma. Fallacious reasoning becomes hence a feasibly mean to avoid the otherwise resulting cognitive dissonance. In other words: in order to accommodate both, the Hippocratic and the moralistic perspective, fallacious arguments may be accepted.
One could therefore formulate the hypothesis that the frequency of consented use of fallacious arguments (or even sophisms) within an otherwise supposedly evidence based discipline may be indicative of (a) a scientifically immature discipline, and/or (b) a moralistically intermingled discipline. Inversely, the progressive decrease of sophisms could then be suggestive of a scientific maturation.

References