Book review: Autism's False Prophets.

Paul A. Offit, M.D., Autism's False Prophets: Bad Science, Risky Medicine, and the Search for a Cure. Columbia University Press, 2008.

Autism's False Prophets: Bad Science, Risky Medicine, and the Search for a Cure examines the ways that uncertainties about autism's causes have played out in the spheres of medical treatment, liability lawsuits, political hearings, and media coverage. Offit's introduction describes the lay of the land in 1916, as polio epidemics raged. That lay of the land, with public fear and willingness to pursue strange, expensive, and dangerous treatments, evokes a strong parallel to the current public mood about autism. It also evokes the hope that our current state is a "before" that (like polio's "before") will be followed by an "after" where sanity prevails about autism's causes and treatments.

Offit gives a clear and engaging description of the early efforts to understand and treat autism. Especially compelling is his discussion of "facilitated communication," and of how it unraveled. (Indeed, the description of how "facilitated communication" was eventually tested is a lovely example of writing that communicates scientific patterns of thought to laypeople by connecting those patterns of thought to everyday critical thinking.) Later, Offit describes how the hopes that secretin would be an effective treatment similarly unraveled.

And then he introduces us to the work of Dr. Andrew Wakefield and the resulting public suspicion of the MMR vaccine.

At this point in the narrative, Offit conveys a sense of just how tangled various issues became -- what the science says, what would be most useful in litigation against vaccine manufacturers, what kinds of vested (but sometimes concealed) interests they key players have, and how parents who are for the most part neither scientists nor physicians weigh their hopes and fears in making decisions around their children's health.

It would be easy for frustration with the parents to dominate, but Offit does a good job of maintaining his empathy even while explaining the uselessness and recklessness of some of their choices. Indeed, some of the parents whose voices he shares here are also doctors and physicians whose hope for improvement in their autistic kids overpowered their objectivity.

I found persuasive Offit's description of how the media has muddied public understanding of what the scientists know about autism. As well, his discussion of how the rules of evidence in a court of law differ from those in the sphere of science was clear and thoughtful.

There are other aspects of this book I found less successful.

For one, the question of objectivity is a sticky one. I think it is useful that Offit exposes conflicts of interest (whether actual or potential) among the scientists clinging to the hypothesis that the MMR vaccine and/or thimerosal are causes of autism, and that he calls attention to the significant profits earned by those selling alternative therapies and diagnostic tests. He points out these financial interest as a counter to the cries of parents that science that supports the safety of vaccines is produced by "pharma shills". There is something appealing about undermining the cries of financially motivated bias on one side by pointing out the potential for financially motivated bias on the other. But this falls short of actually proving that the so-called "pharma shills" are less biased. A more persuasive proof of their objectivity would demonstrate that the results they produce stand up better to attempts to disprove them.

Indeed, because Offit seems to be trying to avoid overwhelming his readers with detailed discussions of scientific methodology, in places he ends up slipping into an argument from authority. There is danger here, as scientists supporting vaccines are painted as white hats, those examining the possibility that they are harmful are painted as black hats, and tort lawyers come across as having black hats and twirling mustaches.

The real world is not that neat.

In some ways, I found this rhetorical strategy most problematic when, in critiquing "junk science" and the credulity of non-scientists, Offit quotes Steven Milloy and Michael Fumento approvingly. Someone does not become an expert merely in virtue of advancing a conclusion with which you agree, nor can someone's expertise be written off because she comes to a conclusion you doubt. The methodology by which the conclusion is reached is what matters -- at least in the realm of science.

Pitting the word of "good experts" against that of "bad experts" doesn't ultimately help parents who are trying to find good information. Rather, it strikes me that giving them more information on how to evaluate that information (and those experts) is what's called for.

Obviously, that's a tall order. However, Offit writes so clearly when he describes how particular hypotheses were tested and found lacking or why particular conclusions were tempting but still in need of rigorous testing that I suspect he could help his non-scientist readers a good way down this path. Indeed, I was disappointed that he didn't say more about the differences between epidemiological studies and the other sorts of studies being bandied about. A thorough understanding of the basic idea behind an epidemiological study might be a helpful thing for a parent (or anyone with a body in need of occasional maintenance) to have ready at hand.

On the whole, I think this book would be a good starting point for a layperson who wants to dig past the hype to the substance of the current state of our knowledge on autism. I'm hopeful, however, that this digging continues past Offit's book to a clearer understanding of scientific methodology. Otherwise, Offit may become just one more expert battling for the hearts and minds of the public.