Aug 01 2008
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.
The most compelling, in my opinion, is his point about “calling in witch doctors.” Yes, I would not be the first exception to that rule. I do have a response, however, and it has to do with the differences between some cultures and our own: the fallacy is that there are “similar inclinations.” There is a vast difference between the traditional, deeply held opinions of a primitive tribesman and his witch doctor, on the one hand, and the addled opinions of a born, raised, and (partially) educated American or European or Australian patient and his snake oil peddling quack on the other. Those in our culture, with occasional exceptions, were not brought up to believe in “CAM.” Many quacks are themselves physicians with no acceptable excuse, who until recently were kept in check by strong professional and governmental pressures, only to have found themselves reborn in a new “golden age of quackery.” Quacks who are not physicians have also been kept in check, until recently, by governmental pressures. Their newfound endorsement by governmental edict is no more justified than would be a similar endorsement of tribal witch doctors.
My major objection, as I’ve written in my bio and elsewhere on SBM, is to “implausible claims being promoted, tacitly or otherwise, by medical schools and government” and by physicians. Patients are not the problem; they are, if you’ll excuse the drama, the victims. Even seemingly benign practices, if implausible, can be harmful (“first, do no harm”), particularly when promoted by someone who should know better. This isn’t the setting for a complete discussion, but it will surely come on SBM. In the meantime, there is the unnecessary expense, a patient later feeling betrayed by her physician when the treatment doesn’t work or the “placebo effect” wears off and she realizes that it was only a “pretend medicine” all along, other patients or physicians concluding that the treatments have validity (and possibly being convinced to forgo rational treatment), people in general losing confidence in modern medicine when it appears that many physicians can’t distinguish between the rational and the bogus, wasted research funds, human subjects unnecessarily duped and endangered, a befuddled media, a befuddled public, befuddled leglislators endorsing quacks to a befuddled public, and more.
Yes, it is true that THIS patient needs help, but if physicians held exclusively to that ethic they wouldn’t have to concern themselves with antibiotic resistance, universal immunizations, judicious use of expensive but very low yield tests that are physically harmless and paid for with pooled money, or other cost-containment issues that don’t immediately affect THIS patient, would they? It’s true that there are many examples where ethical absolutes don’t seem to apply very well.
Moving on to number 2: every pharmacy in Europe that advertises “Homeopathie” is committing fraud, plain and simple. If physicians were more attentive to science and ethics and to explaining things to patients, politicians, and the media, more people would know that. The alternatives to homeopathy for minor or self-limiting complaints, moreover, need not be “NSAIDs or antibiotics or antidepressants” unless there is a good reason for one of them. The alternative is to explain to the patient that the complaint is minor or self-limiting! Why should honesty and integrity be so difficult? That some modern physicians prescribe potent drugs solely for placebo effects (and to get patients out of their offices) is an indictment of that practice, not an argument for “CAM.”
There are, moreover, plenty of rational, nonpharmacological treatments for all manner of minor or self-limiting complaints (and even for not so self-limiting complaints, such as chronic pain), e.g., gargling with hot water or sipping hot tea, time, avoiding environmental allergens, smoking cessation, weight loss, ice packs or heat packs, rest, exercise, massage (to make muscles feel better, not to “remove toxins”), pain management, physical therapy, eating more fibre, “sleep hygiene,” and many more.
The answer to point 3 is the same as the answer to point 2, and I certainly don’t mind if “people feel better for taking a multivitamin or an innocuous herb” (if that were the extent of “CAM” we’d hardly be wasting our time here). I just don’t think that physicians should make false claims. Point 3 also brings psychotherapy to mind. It need not be introduced in an unjustified or insulting way, i.e., by implying that the patient’s symptoms are “all in her head” or are “functional” or whatever. Rather, the honest physician will admit to not being able to explain the symptoms, but acknowledge that they must be distressing and suggest that it might be helpful to discuss how they impinge on the patient’s life and how she might better cope with them.
There are plenty of modern physicians whose patients are not disposed to look elsewhere, even if those patients have “nonspecific tiredness and unhappiness” and even if those physicians don’t suggest woo. Many patients, perhaps most, expect honesty and integrity, and have a pretty good sense of when they see it and when they don’t.
Dr. Moran also added another comment, reproduced in part here:
The ethical objection to ALL use of CAM, as presented by KA, is problematic because of the unspoken assumptions –
1. That conventional medicine has adequate answers to all health problems and the public should be content with what it offers. This applies fairly well to some illnesses but not many others.
2. That “alternative” methods do nothing worthwhile for those using them, anyway. This view is also context sensitive since considerable scientific evidence suggests the likelihood of symptom relief by the placebo medicines of CAM and from interactions with CAM practitioners.
3. That science provides a clear discrimination between what works and what doesn’t. Over the long haul that is true. But what do we mean by “works”? Where does the placebo complex of influences fit in?
Point number 1 is simply incorrect. I have not assumed, nor is the assumption inherent in ethical objections to physicians promoting ”CAM,” that “conventional medicine has adequate answers to all health problems.” I reject, as I hope I made clear above, the false dichotomy that for each health problem there is either a proven treatment or there is “CAM.”
Regarding points 2 and 3, I agree that the only “value” of almost all “CAM” treatments is in their “placebo effects.” But if a physician’s quest to elicit a placebo effect from an implausible treatment means pretending that the treatment has some other effect, specific to the patient’s problem, then that is a lie. So far, I’ve seen nothing to justify such a lie.
There is a potential placebo effect involved in every patient-practitioner interaction, and it needn’t require woo. The most important elements are that the practitioner be attentive and appear to give a damn. Many patients will experience dramatic improvements in symptoms just by finding out that whatever is causing them isn’t cancer or some other serious illness—which reflects an underappreciated reality about the goal of a diagnostic “workup”: not necessarily to determine what something is, but always to determine what it isn’t. The refusal of some physicians and patients to accept that truth is, in my opinion, an important basis for a “CAM” subset, “fad diagnoses” (perhaps a topic for another time).
As a patient, I have experienced two memorable examples of what I think of as “placebo effects.” The first occurred at the age of 18 when, plagued by adolescent angst, I visited a psychiatrist exactly once who told me, “you’re not crazy and you’re not going to go crazy.” I remained an adolescent for some time, but I sure felt a hell of a lot better. The second occurred many years later and was heralded not by a conversation, but by a diagnostic test: after a couple of months of excruciating neck pain, I had a magnetic resonance imaging (MRI) study that showed that my cervical spine was normal. As I read the report the pain abated, never to return to its previous degree of severity.
I am glad that Dr. Moran has described his views on this topic as “tentative positions that I am exploring.” Such candor serves to maintain my view of him as our “conscience,” even as it makes me optimistic that we might dissuade him from making those positions permanent.
The Physician as Expert Consultant
Philosophers Clark Glymour and Douglas Stalker wrote an article 25 years ago for the New England Journal of Medicine titled “Engineers, cranks, physicians, magicians.” It was later reprinted as the first chapter of a book edited by the same authors, Examining Holistic Medicine, which deserves to be on the shelf of anyone interested in the topic. At the time the article was written, the terms “Complementary and Alternative Medicine” (“CAM”) and “Evidence-Based Medicine” (EBM) had yet to enter the lexicon. Other than that it is as timely now as it was then, and is also pertinent to much of the discussion here (note to Dr. Moran: this is no longer directed at you; I know that you are aware of these things). Because the article is not available online I’ve reproduced several passages:
Medicine in industrialized nations is scientific medicine. The claim tacitly made by American or European physicians, and tacitly relied on by their patients, is that their palliatives and procedures have been shown by science to be effective. Although the physician’s medical practice is not itself science, it is based on science and on training that is supposed to teach physicians to apply scientific knowledge to people in a rational way.
The practice of medicine in the United States and in other industrialized nations is a form of consultant engineering. The subjects are people rather than bridges, but in many respects the professions of medicine and engineering are alike. We expect skilled engineers to be able to learn from experience and to get better at building bridges, because we believe that their training has subjected them to a rational discipline that has made them good learners about such matters. Sometimes, of course, we are disappointed. It is entirely the same with physicians, who must apply both explicit scientific principles and also a great deal of tacit knowledge to the treatment of their patients. Medical training is supposed to make physicians good at applying scientific knowledge to sickness, and it is also supposed to make medical doctors good at acquiring through practice an abundance of tacit knowledge useful to their craft.
There is no reason, either historically or logically, to conceive of the science used by physician engineers as necessarily physical science. Engineers need not care in principle whether the generalizations on which they rely are psychological, physical, or psychophysical; what they care about is that the generalizations be applicable and that their reliability be scientifically demonstrated. A great deal of what physicians learn consists of biologic and biochemical generalizations, broadly construed, but they also learn a substantial body of psychophysical generalizations which can be regarded as bridging the crevasse between mind and body. For example, generalizations concerning the effects of drugs, correlating the location of pain with other physical symptoms of disease, and positing the causal factors in dizziness and senility connect the mental with the physical and are thus useful for medical engineering. If physicians learn relatively fewer generalizations that are entirely psychological or social in nature or that posit psychological mechanisms for physical effects, the reason is not that such generalizations are alien to the “medical model” but that relatively few of them are applicable and scientifically warranted.
There are alternative conceptions of the physician. Some of them play a dominant part in the understanding of medicine in other societies, and some serve to qualify the conception of the physician as engineer even in our own society. One such conception is that physicians are consolers. Another is that they are magicians who exercise occult powers to bring about healing. As magicians, they possess magical powers either because of the occult knowledge they possess or simply because of who they are—for example, because they stand in some special relation to gods or demons. Again, the physician may be understood to be someone who applies a reliable body of knowledge that is not warranted by science or by magic but is simply known and, so far as the community is concerned, always has been known. The warrant behind this conception of the healer is tradition and “common knowledge.”
These distinctions are more logical than sociological, and a society may combine several of them in the roles it assigns to healers. A medicine man can combine traditional therapies with magical claims, and both with a bit of consolation. A physician engineer can act as consoler; nothing in either logic or social psychology forbids it. But certain combinations are impossible or extraordinarily unlikely. A physician engineer cannot honestly claim powers of magic or occult knowledge. The principles governing scientific reasoning and belief are negative as well as positive, and they imply that occult doctrines are not worthy of belief. Moreover, physician engineers have no immunity to moral or ethical constraints. On the contrary, they are by training and by culture enmeshed in a tradition of rational thought about the obligations and responsibilities of their profession.
Is there another, holistic, conception of medicine distinct from those described above? Certainly, many people seem to think so. In 1978, a group of medical and osteopathic physicians formed the American Holistic Medicine Association, which now publishes a journal and whose meetings have been recognized for education purposes by the American Medical Association. Popular bookstores are filled with works on “holistic medicine,” many edited by medical doctors and some recommended by such political eminences as Edward Kennedy and George McGovern. The same shelves boast best-selling books on holistic medicine authored by professors at distinguished medal schools and, in at least one case, by a physician administrator at the National Institutes of Health. The therapies described and recommended in a typical book of the genre include biofeedback, hypnosis, psychic healing, chiropractic, tai chi, iridology, homeopathy, acupuncture, clairvoyant diagnosis, human auras, and Rolfing. One of the larger books of this kind was even subsidized by the National Institute of Mental Health.
What ties together the diverse practices…? In part, a banal rhetoric about the physician as consoler;… In part, familiar and rather useless admonitions about not overlooking the abundance of circumstances that may contribute to one condition or another. Such banalities are often true and no doubt sometimes ignored, with disastrous consequences, but they scarcely amount to a distinctive conception of medicine. Holist therapies can be divided into those that are adaptations of traditional medical practices in other societies—Chinese, Navajo, and so forth—and those that were invented, so to speak, the week before last by some relatively successful crank.
Insofar as it extends beyond banality, the holistic medical movement constitutes both a deliberate attempt to substitute a magical for an engineering conception of the physician and an attack on scientific understanding and reasoning. Although the holistic movement does not contain a conception of medicine distinct from those we have discussed, it does contain a reactionary impetus to return the practice of medicine to the practice of magic and to replace logic and method with occultism and obfuscation.
Several conceptions of “holism” have been developed in the writings of holistic practitioners and their advocates. Most of them are vacuous; they are banalities of orthodox medicine, or they have no medical content and no applicability to any possible practice of medicine; they merely sound nice. Some are patently false. A much-repeated and trivial thesis, and moreover one that is said to characterize the sense in which holistic medicine is “holistic,” amounts to no more than this: mental and physical properties are interdependent. Mental states affect physical states and physical states affect mental states. No one doubts it. To make such a claim seem somehow profound, holistic writers invariably conjoin it with a discussion of Cartesian dualism, insinuating that modern medicine follow Descartes in postulating an impassable chasm between the mind and the body. Modern medicine does no such thing, and could not even if it wanted to, since Descartes held no such view.
Another doctrine said to be holistic is that one’s state of health is affected by everything. Whatever this means, it has nothing to do with any possible practice of medicine, for no one can attend to everything. If physicians cannot distinguish relevant from irrelevant factors, important from unimportant causes, then they can do nothing. A variation of this doctrine is not vacuous but merely vapid: “Fundamental to holistic medicine is the recognition that each state of health and disease requires a consideration of all contributing factors: psychological, psychosocial, environmental, and spiritual.” [Pelletier 1979] This is not a new revelation about medicine. Insofar as such multiple factors are known and believed to be important, they are routinely addressed in conventional medicine practice. Patients who suffer from coronary heart disease may be treated with beta blockers and antiplatelet drugs, and they may also be advised to change their work, their diet, their smoking habits, their exercise habits, and their living conditions.
The essay discusses assertions that “ ‘all states of health and all disorders are considered to be psychosomatic’ [Pelletier 1977]“ and that “the entire body (and psyche) can be treated or diagnosed through the treatment or observations of a special part of the anatomy.” Because of such notions,
…holistic practitioners…are under no obligation, they believe, to reconcile their claims about therapy with what is known about the causal pathways of the body.
The holistic practitioner sees the body in much the same way that magicians of old viewed the universe. The body becomes the last bastion of magic.
The authors expose the fallacy of the argument that “holistic medicine has not really been investigated, that funds ought to be made available for conducting tests of holistic practices, and that meanwhile we should keep our minds open about holistic techniques.” Although they couldn’t have foreseen the scientific blind spot that would soon hamper academic medicine in the form of “evidence-based medicine,” the authors portend discussions of Prior Probability:
Although it might be interesting to know more about the physiological pathways that are correlated with such processes as the placebo effect, this has nothing do with taking seriously the claims advanced by iridologists or zone therapists or even chiropractors. The claim to diagnose by examining the eye or to cure by massaging the foot is completely bogus; we know more than enough about the workings of the body to be reasonably certain that geometric features of the iris, for instance, do not provide the specific information about disorders that iridologists claim they do….Of course, it is conceivable that the beliefs of scientific medicine are in error about one or another of these matters, but that is no reason for using public funds to investigate holistic claims. One cannot justify spending other people’s money simply because one can imagine something to be true. The mere fact that holistic medicine is widespread and enduring is no reason to take its claims seriously; superstition, self-deception, stupidity, and fraud are ubiquitous and always have been.
The authors refute the charge that “the lack of evidence concerning the specific curative powers of holistic therapies is the result of a conspiracy of disinterest.” They dispense with cultural relativism, another favorite refuge of IMC advocates, and demolish the ”differing paradigms of Thomas Kuhn” contrivance:
Holistic advocates repeatedly cite Kuhn and claim that holistic medicine is an alternative paradigm with its own standards, one that cannot be understood or assessed by the practitioners of orthodox medicine. If the claim were valid, holistic practice would have to constitute a scientific tradition, albeit one in competition with the tradition of orthodox medicine. However, holistic medicine is not a scientific tradition. It has no paradigmatic work, no recognized set of problems, and no shared standards for what constitutes a solution to those problems; it also lacks the critical exchange among its practitioners that is characteristic of the sciences. Cranks have been common throughout the history of science, as Kuhn, a distinguished historian of science, knew well. The work of cranks does not constitute a scientific revolution, and no cranks appear among Kuhn’s many examples.
Glymour and Stalker were prescient in their conclusion:
If holistic-health advocates were content with encouraging sensible preventive medicine or with criticizing the economic organization of American medicine, we might be enthusiastic, but they are not. If the movement were without influence on American life, we would be indifferent, but it is not. Holistic medicine is a pablum of common sense and nonsense offered by cranks and quacks and failed pedants who share an attachment to magic and an animosity toward reason. Too many people seem willing to swallow the rhetoric—even too many medical doctors—and the results will not be benign. At times, physicians may find themselves in sympathy with the holistic movement, because some fragment of the rhetoric rings true, because of certain practices and attitudes they encounter in their daily work with colleagues and patients, or because of dissatisfaction with the economic and social organization of medicine. One hopes they will speak bluntly, but it does no good to join forces with cranks and quacks, magicians and madmen.
Amen to that.
Next week: Loose Ends
* The Science, Reason, Ethics, and Modern Medicine series:
Science, Reason, Ethics, and Modern Medicine Part 1: Tu Quoque and History
Science, Reason, Ethics, and Modern Medicine, Part 3: Implausible Claims and Formal Ethics Statements
Science, Reason, Ethics, and Modern Medicine, Part 4: is “CAM” the only Alternative? And: the Physician as Expert Consultant
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