The Sectarian Temptation

Peter Hotez published a working paper last October that names something most of us feel but few have articulated this cleanly: American medicine has always been split between a scientific camp—defined by falsifiability, methods, and the willingness to be proven wrong—and a sectarian camp, defined by narrative certainty, personal testimony, and claims that conveniently can't be disproved. His argument is that the wellness-influencer economy is the latest iteration of a pattern older than the AMA itself.

He's right. And what struck me reading it wasn't the history or the policy prescriptions. It was the realization that palliative care sits directly on the fault line he's describing—and that we need to talk about it more.

We work in the places where evidence gets thin, emotions run hot, and the mysteries are real. Consciousness at end of life. The nature of suffering. Prognostic fog. What happens after (and why before sometimes takes so damn long). That territory is ours, and it matters. But it is also the exact territory where sectarian certainty rushes in with confident answers, unfalsifiable frameworks, and the seductive promise that someone, somewhere, has figured it all out.

The question isn't whether mystery exists. It does. The question is what we do with it.

The Old Split, Rebranded

Hotez traces the scientific-versus-sectarian divide back roughly two hundred years, to physicians trained in the Scottish Enlightenment tradition clashing with homeopaths, eclectics, and botanical healers. The Flexner Report of 1910 was supposed to settle it. It didn't. The divide just migrated—through chiropractic battles, anti-fluoridation movements, Laetrile clinics, and now into a multi-billion-dollar wellness-influencer economy that packages old sectarian impulses in new branding.

Steven Novella has written extensively about why scientific plausibility matters as a filter: claims need to survive contact with methods and reality, or they aren't medicine. They're belief systems. The distinction sounds obvious. In practice, it's anything but—especially when the patient in front of you is dying and neither of you has a satisfying answer.

Here's the core of it: scientific medicine is defined by its willingness to be wrong. Sectarian medicine is defined by its immunity to disproof. One updates. The other pivots.

If your theory can't lose, it isn't medicine. It's a creed.

Why Palliative Care Is the Stress Test

Most of medicine can at least gesture toward clean endpoints. The tumor shrank or it didn't. The A1c dropped or it didn't. Palliative care rarely has that luxury. We manage subjective symptoms—pain, breathlessness, nausea, fatigue—that resist tidy measurement. We sit with existential suffering that doesn't have a CPT code. We navigate prognostic uncertainty so profound that our best tools are sometimes indistinguishable from educated guessing.

This is high-emotion, high-uncertainty care. And uncertainty is where confident-but-untestable narratives find their opening.

The numbers confirm what you already feel. A 2023 multicenter survey of terminally ill patients in palliative care found 88% lifetime prevalence of complementary and alternative medicine use—and nearly one in five had discontinued mainstream treatment because of it. A 2018 JAMA Oncology cohort study of 1.9 million patients found that complementary medicine use was associated with twice the risk of death—not because the complementary interventions were themselves toxic, but because they were associated with refusal of conventional treatment. The sectarian pull isn't abstract. It has a body count, and it's mediated by the very thing palliative care claims as its core competency: the decision-making conversation.

You've seen the clinical version at the bedside. A family arrives asking about IV vitamins and "root-cause detox" while you're managing refractory dyspnea and trying to explain why Dad is confused.

Here's the uncomfortable part: some of what we do exists in a gray zone too. Not all of our interventions have robust evidence. Not all of our frameworks have survived rigorous testing. Music therapy, aromatherapy, some complementary approaches integrated into palliative programs—the evidence base is thin or mixed. The difference—the only difference that matters—is whether we submit our claims to methods that can prove them wrong. Whether we update when the data arrive. Whether we hold our convictions lightly enough to let go of them when they stop earning their place.

"Serious illness often has multiple contributors. We may not find one cause, but we can still lessen suffering in concrete ways." That's a sentence worth practicing until it's natural, because it does two things at once: it disarms the root-cause absolutism of functional-medicine rhetoric without resorting to dismissiveness, and it models the honest uncertainty that our patients actually need from us.

Placebo and Nocebo: Facts of Practice, Not Insults

This is the part that makes people defensive. It shouldn't.

Placebo and nocebo effects are real, clinically significant psychobiological responses. They are not synonyms for "fake" or "gullible." They are the measurable impact of context, expectation, learning, and communication on a patient's mind, brain, and body. Colloca and Finniss established in JAMA that nocebo effects operate during routine treatments—not just in sham-pill studies—negatively affecting outcomes through negative information and prior unsuccessful therapies. The implication is direct: how we talk to patients changes what happens to them physiologically.

Let that land for a moment. Communication is not just rapport-building. It's an intervention with measurable outcomes. Verbal suggestions, framing, prior experiences—all of these modulate symptom perception. Every serious illness conversation we have is simultaneously a clinical and a psychobiological event.

The evidence has gotten harder since these effects were first described. An updated 2025 meta-analysis of 60 randomized controlled trials found that even open-label placebos—where patients know they're receiving a placebo—produce measurable benefit (SMD 0.35 across outcomes), with significantly stronger effects for self-reported outcomes than objective ones. That distinction matters for us. Palliative care outcomes are overwhelmingly self-reported: pain scores, dyspnea scales, quality of life measures. We are working in the exact domain where meaning, context, and expectation exert their strongest measurable effects. That is not a confession of weakness. It's an argument for why communication science belongs at the center of our training, not the periphery.

Lucas and Booth's review in BMJ Supportive & Palliative Care made the palliative-specific case: placebo effects—driven by the therapeutic relationship, the context of care, and the significance of meaning—likely contribute to symptom relief across pain, breathlessness, and depression. They may also underlie much of what patients experience as the benefit of complementary therapies. Recognizing this isn't an endorsement of pseudoscience. It's an acknowledgment of mechanism.

Placebo is not fake. It's the clinical impact of meaning, context, and trust—and you're deploying it whether you acknowledge it or not.

The ethical and practical challenge is that the same mechanism cuts both ways. Nocebo effects—harm generated by negative expectations and communication—are equally real. When we say "this medication causes nausea in 40% of patients," we are not just informing. We are priming. The expert consensus led by Evers, Colloca, and colleagues laid out evidence-based recommendations for how clinicians should discuss these effects: transparently, but with deliberate attention to framing. Not lying. Not withholding. Framing with care.

In practice, this means replacing threat-heavy scripts with language that preserves agency: "Some people notice nausea; if that happens, call us—we have options" rather than "This causes nausea." It means scripting what I'd call epistemic consent—telling patients and families the triad: "Here's what we know. Here's what we don't. Here's what we're watching for." That framing inoculates against sectarian certainty by normalizing uncertainty. It says: we don't need to pretend we have all the answers to still be useful.

The Ethic: Rigorous Science, Humble Methods

So where does this leave us? Three commitments, none of which are optional.

Method humility. We update beliefs as evidence changes. We insist on plausibility filters and testability—not because we worship the scientific method as an end in itself, but because it's the best tool humans have built for distinguishing "this might help" from "I wish this would help." We don't need perfect evidence to act; palliative care would barely exist if that were the bar. But we need intellectual honesty about the quality of evidence behind what we recommend. And when the evidence arrives and contradicts our priors, we change. Publicly, transparently, without hand-wringing.

Meaning realism. We embed the empirical fact that communication and context modulate outcomes into our training and our practice. Deliberately. This isn't soft skill decoration; it's a clinical competency with a measurable mechanism. If we train fellows to titrate morphine, we should train them to titrate language with equal precision. The data support it. The ethics demand it.

Boundary clarity. We do not launder unfalsifiable claims as "holistic." We do not let comfort serve as proof. "Integrative" earns its name when it means aligning interventions with evidence, plausibility, patient values, and actual outcomes—and measuring what happens. It does not earn its name by granting immunity to disproof. When someone claims that an intervention works but can't be tested, that the evidence is "too subtle for RCTs," that criticism itself is the problem—those are sectarian cues, and we should name them.

Red flags to recognize quickly: claims that are unfalsifiable; claims that pivot when disproven; the rhetoric of "they don't want you to know"; and care models that monetize supplements or proprietary testing as the center of the therapeutic relationship. You've heard all of these. The discipline is in calling them what they are—without becoming the kind of rigid, dismissive physician that drove people to sectarian alternatives in the first place. A 2023 study in The Oncologist found exactly this dynamic: patients who declined conventional cancer treatment in favor of CAM described feeling disempowered and diminished by their physicians. Poor communication wasn't a side note in their decision—it was a driver. Every dismissive encounter is a recruitment event for sectarian medicine.

Where I Might Be Wrong

A few things that would shift my thinking here.

First, the general placebo and nocebo literature has matured significantly—open-label placebo trials now number in the dozens with consistent effect sizes—but the palliative-care-specific application remains underdeveloped. Lucas and Booth's review is a narrative synthesis, not a meta-analysis. We have strong mechanistic plausibility and converging evidence from adjacent fields, but we don't yet have the palliative-specific trials that would support standardized communication protocols designed to optimize placebo and minimize nocebo. That gap is ours to close.

Second, there is a real risk that "boundary clarity" becomes a cudgel. If the scientific camp uses plausibility filters to dismiss patient experience—"your acupuncture didn't work; you just felt better because of context"—we've lost the plot. The point is not to strip meaning from care. It's to ensure that meaning is built on honest foundations rather than marketed mythology.

Third, Hotez's frame, powerful as it is, focuses on the U.S. context and on the political dimensions of the multi-billion-dollar MAHA influencer movement. The palliative care application I'm drawing here extends his argument into clinical territory he didn't specifically address. That's my extrapolation, not his thesis. If you disagree with my extension, argue with me—not with him.

The Job Is to Do Neither

We don't know everything about dying. We know a great deal about suffering, and we have real tools—pharmacologic, communicative, structural—to address it. Those tools deserve rigorous stewardship, not mythological inflation.

When medicine pretends there is no mystery, people flee to sects. When we treat mystery as sacred knowledge, we become one. The job is to do neither.

Palliative care should be where we prove you can honor mystery without inventing myths. Where evidence and humility coexist without one swallowing the other. Where "I don't know" is not a failure of competence but a foundation for trust.

That means training communication as a clinical science, not an afterthought. It means holding our own interventions to the same evidentiary standards we apply to the IV vitamins and the root-cause rhetoric. It means being the field that says, clearly and without apology: "We work at the border of the knowable. We take that seriously. And we refuse to fill the gaps with anything other than honest, disciplined, revisable science delivered with the full weight of human meaning."

That's not a retreat from what makes palliative care special. It's the most ambitious possible version of it.

I am a palliative care physician, educator, and professional strategery expert. Known for turning rounds into rants and rants into teaching points. Rounds & Rants represents my views — not those of any institution or professional membership organization where I hold a role. I don't write on their behalf and they don't vet what I publish.