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Science, Reason, Ethics, and Modern Medicine, Part 4: is “CAM” the only Alternative? And: the Physician as Expert Consultant

Dr. Moran Weighs In

In last week’s post, I dubbed Dr. Peter Moran the “conscience” of SBM, citing his commitment to doing what’s best for individual patients even if, in theory at least, that may involve some manner of benign but fanciful treatments. I countered with my own opinion that honesty and integrity are necessary parts of any discussion with a patient, and that they, in turn, must not conflict with science and reason.* I added passages from a couple of key medical ethics treatises to support my assertion. Dr. Moran’s response, thoughtful and provocative as always, was buried in the midst of other commenters’ tangential arguments about the theory of evolution. Rather than continue its exile there, I reprint it here to give it the exposure that it deserves:

A blatant appeal to authority, but one that I mostly agree with. The difference between us is that I insist that medicine is about an infinite number of individual contexts and I see many examples where ethical absolutes (actually these are ethical guidelines rather than directives) do not apply or don’t seem to apply very well.

We scientists are ever-so cautious when making scientific judgments about complex matters; let’s not pretend that arriving at absolutes in medical ethics is a piece of cake, especially when it is not quite clear how anything done with the undiluted welfare of the individual patient in mind can be entirely unethical. I mean, why are we obliged to consider the impact of our decisions upon the fate of the planets (or whatever) when THIS patient needs help? In fact, at least one medical ethicist has gone so far as to state that it is not unethical for a doctor to prescribe a placebo treatment, so long as the doctor believes it will benefit the patient. I don’t quite agree with that bald statement — there should be a rider specifying that this may apply to *some* contexts where there is no obviously superior evidence-based method.

Here are some examples of the intellectual minefield we have to negotiate.

1. All the doctors I know would be prepared to call in the witch-doctor if it would help assuage the fears, or help in the management, of a seriously ill primitive tribesman. It seems we are prepared to pander to the superstitions of SOME cultures while despising any similar inclinations in our own.

2. I have previously asked this question which has to do with public policy in relation to safe “alternatives”. Take my word for it that every pharmacy in Europe displays “Homeopathie” (or language equivalents) in large letters outside. Would skeptics prefer those using such remedies for their minor and self-limiting complaints to be using NSAIDs or antibiotics or antidepressants instead, treatments that will often in such contexts themselves perform no better than placebo, but at substantially greater risks? Behind the usual healthfraud position there is both an exaggeration of the capacity of modern medicine and insufficient recognition of the harm that it can do. We definitely do not yet have entirely safe and 100% effective solutions to all of mankind’s ills, and certain imperfections of everyday medical practice can heighten the risks of the use of unnecessarily powerful pharmaceuticals. So what is the safest and most pragmatically realistic position here?

3. Following on from that — what is the evidence-based answer to non-specific tiredness and unhappiness? If people feel better for taking a multivitamin or an innocuous herb, why should we care? We keep on offering the public temporary answers to these things, prescribing (historically) amphetamines, cocaine, opiates, barbiturates and phenothiazines in massive quantities, only to take them away when problems such as addiction ensue. Is it right to then turn around and say, well you didn’t really need these things anyway, even denying them any relief that they may derive from “pretend medicines”. The science that matters will be argued out in other arenas.

That’s to give you some idea of the kind of thing that I am on about. You seem to think I am talking about doctors promoting CAM or placebo treatment as a matter of policy. I am not prepared to go that far, although I think I understand why some doctors might do that.

I agree that “medicine is about an infinite number of individual contexts and [there are] many examples where ethical absolutes do not apply or don’t seem to apply very well.” Nor did I really think that Dr. Moran was “talking about doctors promoting ‘CAM’ or placebo treatments as a matter of policy.” We disagree elsewhere, but he makes some interesting points.

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Science, Reason, Ethics, and Modern Medicine, Part 3: Implausible Claims and Formal Ethics Statements

The Ethics of Implausible Medical Claims (IMC)

In Part 2 of this series* we learned from David Katz, MD, a key member of the Yale School of Medicine’s “integrative medicine” program, that he had been “pushed toward integrative medicine by the needs of [his] patients.” We also learned that Dr. Katz’s rationale for this decision justifies a wide range of quackery—both in principle and in fact. I had previously alluded to arguments like those of Dr. Katz in a comment on SBM several months ago:

…we must be true to medical ethics, no matter what else we do. If that means losing a few patients, so be it. Patients are free agents, and we can only do so much to influence them. To the extent that we don’t do that as well as we might (which is obviously true in some cases), we might do better. But our ethical obligation is to science and truth; it is not, as many modern physicians would have it and as much as we may lament sometimes losing patients to woo, to seducing patients to stick with us no matter what, if the “what” includes engaging in a charade about “integration” or “complementary therapies”…

Realizing that some might argue that physicians’ obligations to patients ought to trump their obligations to “science and truth,” I later revised that statement:

Several weeks ago I argued here that a physician’s primary ethical obligation is to science and truth. In retrospect I probably should have put it a slightly different way: a physician’s primary ethical obligation is the same as everyone else’s. It is to honesty and integrity. For physicians, however, that means being true to real medical knowledge, among other things, and real medical knowledge comes from science.

In spite of that revision, two readers whose opinions I respect challenged my assertion. Dr. Peter Moran’s worthy efforts to educate patients about the realities of “alternative” cancer treatments are considerable. Here on SBM he has repeatedly challenged us to explain how, when confronted with testimonials of “alternative” cures, we ought to respond without using “a high-handed, ‘we know best’ stance” and thus “appear to want to distance [ourselves] from the intimate concerns of [our] patients.” I was thinking mainly of him when I wrote the revision above, because on this key topic—how to respond ethically, but with compassion, to patients who want to believe in implausible treatments—I’ve come to think of Dr. Moran as the “conscience” of Science-Based Medicine. Those with cancer, he has reminded us, “are folk very like you and me who are simply grasping at any straw that might save or prolong their lives.” His take on why IMCs are appealing to those with less ominous problems is well-developed and agrees with my own, mostly. We part ways, however, when he concludes (also here and here) that ethical physicians might have good reasons—unlike Dr. Katz’s—to entertain benign, if implausible treatments:

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Posted in: Health Fraud, Medical Ethics, Science and Medicine

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Science, Reason, Ethics, and Modern Medicine, Part 2: the Tortured Logic of David Katz

In Part 1 of this series* I asserted that a physician’s primary ethical responsibility is to honesty and integrity, which in turn must be largely based on science and reason (I apologize if that sounded preachy; if there had been more time I might have couched it in more congenial terms). I mentioned the fallacious reasoning whereby proponents of implausible medical claims (IMC) point to real and imagined weaknesses of modern medicine to justify their own agenda. I offered, as a favorite example of such proponents, science-based medicine’s having not yet solved every health problem. This week I’ll show how this version of the tu quoque fallacy has led a prestigious medical school to advocate pseudoscience-based medicine.

Modern Medicine: a Brief, Fragile Commitment to Science

First, a few more words about the title of this series. Modern medicine is not science, even if it draws upon science for its knowledge: it is an applied science similar, in that sense, to engineering. Modern medicine is also not synonymous with the “medical profession,” if the term means the collection of all people with MD degrees. That is true for the obvious reason that medicine is more than people, but also because a small but loud minority of MDs rejects modern medicine and science.

Modern medicine has made an uneven commitment to science and reason. At its best, it has formally embraced them in the faculties and curricula of medical schools, in its codes of ethics, and in its contributions to knowledge, both basic and applied, over the past 150 years or so. As discussed last week, it is because of science and reason that modern medicine has made dramatic, revolutionary advances in a very short time. That is what distinguishes it from every other “healing tradition,” and why there is no legitimate competition. The only valid medicine in the modern world is science-based medicine—not “allopathic,” “Western,” “conventional,” “regular,” “integrative,” “complementary and alternative,” or any of the so-called “whole medical systems.” The pre-scientific (and, ironically, “post-modern”) designation of “schools” or “systems” of medicine, so stridently trumpeted by quacks, is an anachronism—even if it persists in archaic, governmental edicts.

Compared to the actual sciences, however, modern medicine’s commitment to science is fragile. Its recent confusion of error-prone clinical trials with science itself—the project called “evidence-based medicine”—has been a mixed blessing. Its growing tolerance of charlatans and crackpots, at times elevating them to celebrity status, would be unthinkable in physics or biology. Its dalliances with quackery, so depressingly recounted in recent posts here, here, here, and here, are why your SBM bloggers do what we do. Biologists, other scientists, and intellectuals in general have joined the battle against the pseudoscientific travesty known as “intelligent design.” Many physicians, however, even of the brainy, academic variety, act as though the equally pseudoscientific but more dangerous travesty known as “integrative medicine” is either a good thing or, at least, is a necessary addition to medical school curricula.

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Posted in: Health Fraud, Medical Academia, Medical Ethics, Science and Medicine

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Death by “alternative” medicine: Who’s to blame?

One of the more annoying duties I used to have several years ago at our cancer center was to “show the flag” at our various affiliates by attending their tumor boards. I say “annoying” not so much because the tumor boards themselves were onerous or even uninteresting but rather because traveling to them used to cut into my already limited time for research, given that these tumor boards were always scheduled on days on which I didn’t have to be in clinic or the operating room. In other words, they always took place on my research days.

One of our affiliates was a nearly an hour and a half drive away, and many of them were close to an hour away. When you add up travel time and the tumor board, that’s easily more than three hours eaten up, all too often right in the middle of the day. In actuality, though, several of the tumor boards themselves were quite good, one of which being the aforementioned one that required nearly a 90 minute drive to reach. (It helped that they served a really nice breakfast there, too, but they also have really stimulating discussion about various cancer cases.) One of the weird things about these tumor boards is that I was viewed as–and I quote–the “outside expert.” This was particularly disconcerting the first year I had the job. There I was, fresh out of fellowship, being looked up to as the “expert” by physicians, many of whom who may have been in practice for 10, 20, or even 30 years. Somehow I managed to muddle through without making too big a fool of myself. These days, years later, I almost even feel as though, for breast cancer at least, I am worthy of the appellation of “outside expert.” Experience does matter, I guess.
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Another State Promotes the Pseudoscientific Cult that is “Naturopathic Medicine.” Part 4

The “Science” and Ethics of “Natural Medicines” (and Nutrition) cont.

This is the continuation of a discussion concerning the explicit claim of “naturopathic physicians”* to being experts in the use of “natural medicines,” defined as “medicines of mineral, animal and botanical origin.” Last week’s post established that the cult has chosen to profit from the “retail selling of medications,” as evidenced by the relevant Position Paper of the American Association of Naturopathic Physicians (AANP) and by that organization’s having made a deal with a drug company to make profits for both itself and its members.

The Position Paper observes that such selling “could be construed as a conflict of interest on the part of the physician.” That is true, if embarrassingly understated: anyone representing himself as a physician, who both recommends and sells the same medications for a profit, has conflicting interests. The conflict undermines his claim to offering responsible advice regarding those medications, and as such is a breach of medical ethics.

The AANP’s deal with MotherNature.com was even worse: by promoting such peddling in a formal, institutional fashion, NDs and their national organization went beyond the already widespread problem of practitioners hawking drugs. It is unclear whether the deal still exists, by the way: MotherNature.com was a victim of the “dot com” bust of a few years ago. It has since been resurrected, but a quick perusal of its new website fails to reveal the old AANP relationship. Nevertheless, I have seen no evidence to suggest that the AANP has changed its view of that sort of deal.

Are NDs Truly “Learned Intermediaries” in the Use of “Natural Medicines?”

This entry discusses the other part of the claim of expertise: that, aside from their conflicting interests, NDs have real knowledge of “natural medicines.” It will become clear during the discussion that the purported naturopathic expertise in nutrition—another standard claim—is also under review. I will include or cite abundant evidence for my assertions, because I’ve found that a predictable response of representatives of the highest levels of “naturopathic medicine” is to flatly deny them. I apologize again for including excerpts from previously published material.

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Posted in: Book & movie reviews, Health Fraud, Herbs & Supplements, Medical Ethics, Nutrition, Politics and Regulation

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The Bait and Switch of Unscientific Medicine

Savvy consumers are familiar with the classic scam of the “bait and switch” – in practice if not the term itself. My wife and I ran across it when we were shopping for our first car. We needed a bargain and so we were attracted to the ads that promised a new Colt for only $9,000 (that’s the bait). Of course when we got to the dealership they were all out of Colts with the configuration advertised, but they had plenty of others that had different options that cost several thousand dollars more (that’s the switch).

It’s a basic and very successful form of deception, and so even though there are laws against such practices it is impossible to eliminate in all its various and more subtle forms. It even permeates scientific, political, and other intellectual endeavors – anytime a more palatable idea or claim is put forward to represent the less acceptable truth.

Science, however, requires transparent honesty to function properly, and therefore scientific practitioners must vigilantly guard against the cognitive bait and switch. Generic intellectual virtues incorporate this vigilance – they include the need to unambiguously define terms, to make claims as specific and operational as possible, and the use of valid logic. Beware of any claims that subtly violate these rules because they are probably setting you up for a bait and switch.

The purveyors of unscientific medical claims have become as expert at this classic deception as the slickest used-car salesman – in fact they have left the hawkers of dubious transportation in the dust.

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Chiropractic Strokes Again! A Landmark Lawsuit in Canada

Sandra Nette is a prisoner, condemned to spend the rest of her life in the cruelest form of solitary confinement. Her intact mind is trapped in a paralyzed body and she is unable to speak. She can move one arm just enough to type on a special keyboard. She cannot swallow or breathe on her own, and must be frequently suctioned. She feels sensations and is in pain. Her condition is known as “locked-in syndrome” and has been described as “the closest thing to being buried alive.” She is suing those responsible for her cruel fate and I hope she wins.

She was a healthy 40 year old woman who wanted to stay healthy. She did all the right things like watching her weight, eating right, and not smoking. She followed the advice of a chiropractor to include regular maintenance chiropractic adjustments in her health regimen. On September 13, 2007 she had the last adjustment she would ever have.

There was nothing wrong with her. She didn’t see the chiropractor for headaches, neck pain, back pain or any other complaint. She went for a “tune-up” that she thought would help keep her healthy. The chiropractor did a rapid-thrust adjustment on her neck. Right afterwards, she complained of feeling “sore, dizzy and unwell.” She tried to leave but had to sit down. The chiropractor failed to recognize the medical emergency, and instead of calling an ambulance he recommended that she would benefit from purchasing massage therapy from his clinic. He let her leave the office and drive home alone. She only made it part way. (more…)

Posted in: Chiropractic, Health Fraud, Politics and Regulation

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Another State Promotes the Pseudoscientific Cult that is “Naturopathic Medicine.” Part 3

The “Science” and Ethics of “Natural Medicines”

This and the next entry in the current “Naturopathic Medicine” series* deal with the cult’s claim of expertise in “natural medicines” or “natural remedies.” These include herbs (“botanicals”), glandular extracts, vitamins, and minerals. A large fraction of the Textbook of Natural Medicine (TNM), “the most thoroughly researched and carefully referenced text on natural medicine,” is devoted to these agents.[1] They are keys to the practice of naturopathy and to a core claim of “naturopathic physicians” that legislators tend to swallow: that NDs offer something that most MDs do not.

During the deliberations of the Massachusetts Special Commission, NDs produced Dr. Alan Trachtenberg, a fresh-faced ingenue who had briefly been Acting Director of the federal Office of Alternative Medicine, to testify on their behalf. He suggested to the Commission that naturopaths could be the “learned intermediaries” that the public needed to help make sense of the myriad “natural remedies” that became freely available in the wake of the Dietary and Supplement Health and Education Act of 1994 (DSHEA). This is from his written testimony:

Another advantage of state licensure, is that the holder of a professional license who provides or recommends a product, then becomes responsible for the quality and safety of a product. In an unregulated marketplace, such a learned intermediary can be invaluable to the consumer. Since naturopaths do often provide dietary supplements and herbal products directly to their patients, it is vital that they have an enforceable code of professional ethics. Such a code of ethics becomes enforceable with State licensure.

It is also beneficial for the patient to have a practitioner who knows enough about biochemistry, physiology, pharmacology, and physical diagnosis to adequately assess a patient’s clinical response to a product. These products are essentially complicated but unregulated drug mixtures. My understanding is that licensable naturopathic doctors have all taken these courses during their four years of training and passed standardized exams that test their mastery. There is no such quality assurance for the other kind of naturopathic practitioner.

Instead of relying on Dr. Trachtenberg’s “understanding,” let’s submit his two assertions—that of a “code of ethics” and that of “mastery” of the topic of “natural medicines”—to real scrutiny. In doing so I confess that I have plagiarized, to some extent, pieces that I’ve written elsewhere.

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Posted in: Health Fraud, Herbs & Supplements, Medical Ethics, Politics and Regulation

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Another State Promotes the Pseudoscientific Cult that is “Naturopathic Medicine.” Part 2

The “Safety of Naturopathic Treatment”

In their nationwide effort to convince lawmakers to pronounce them primary care physicians, “educated” naturopaths have repeatedly claimed that their “natural” treatments are “safer and gentler” than those offered by medical doctors. The Alliance Legislative Workbook, a website that for several years provided strategies and “talking points” for ND-activists seeking state licensure, made this assertion in 2001:

Malpractice insurance rates [for licensed NDs] are generally less than $4000.00 per year, indicating the safety of naturopathic treatment as assessed by insurance companies. Master Insurance Trust reports that of the naturopathic physicians for whom MIT provides liability insurance, there have been only four incidents reported to the company for follow-up. However, nothing has been paid in either settlements or judgements on any of these items. “While this pooling of physicians is much too small to base actuarial considerations, this claims experience is clearly superior.” (Jeffrey D. Brunken, Program Manager, MIT, Letter dated May 21, 1990.)

Jury Verdicts Northwest, a legal database which records court cases in Washington and Oregon, the area of the country with the largest number of naturopathic physicians, shows no judgments for malpractice against N.D.s since the database was started in 1983. One in five M.D.s is sued each year in the US (AMA).

Why is malpractice so much lower among naturopathic physicians?

Naturopathic methods are less likely to cause injury than orthodox methods. Prudent dietary and lifestyle changes, for instance, are unlikely to cause harm. Naturopathic physicians by philosophy and training use the least invasive means to treat and prevent disease. This results in less injury to patients. Naturopathic physicians also have excellent diagnostic and referral skills. There is no significant history of complaints against naturopathic physicians resulting from a missed diagnoses, the most common cause for suits in a general practice. From insurance data, it appears that naturopathic physicians as a group know the limits of their methods and refer patients to other practitioners or specialists when appropriate.

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The FDA Cracks Down on Fake Cancer Cures

The Food and Drug Administration (FDA), the agency that regulates the drug industry in the US, put out a press release yesterday warning “Individuals and Firms to Stop Selling Fake Cancer ‘Cures’.” The press release reports:

“Although promotions of bogus cancer ‘cures’ have always been a problem, the Internet has provided a mechanism for them to flourish,” said Margaret O’K. Glavin, the FDA’s associate commissioner for regulatory affairs. “These warning letters are an important step to ensure that consumers do not become the victim of false ‘cures’ that may cause greater harm to their health.”

The FDA therefore recognizes that this is a serious problem, and that is good. They also acknowledge that the problem of “bogus cancer cures” is a longstanding one, not a new or recent problem, but the reason they are taking action now is because the internet is significantly increasing the reach of these fake cures.

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Posted in: Cancer, Health Fraud, Politics and Regulation

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