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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.

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.” [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 2: the Tortured Logic of David Katz

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

Science, Reason, Ethics, and Modern Medicine, Part 5: Penultimate Words

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

Leave a Comment (40) ↓

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

  1. Harriet Hall says:

    Excellent post with much food for thought and some great sound bites. My favorite: “The work of cranks does not constitute a scientific revolution”

    Words of wisdom.

  2. qetzal says:

    Dr. Moran’s hypothetical about witch doctors struck me as provocative, but after further consideration, I’m not sure it teaches us anything new.

    If an MD agreed to a tribesman’s request for a witch doctor, and the witch doctor’s role was just to assuage the tribesman’s fears, isn’t that equivalent to having the hospital chaplain stop by to comfort a seriously ill patient? I don’t mean to suggest that religion is equivalent to shamanism, only that the MD is responding to the patient’s request for psycological/spiritual/cultural support from someone the patient trusts. I see nothing wrong with that, even if the MD disbelieves in both shamanism and religion.

    Alternatively, if an MD called in the witch doctor on his own initiative, that’s more problematic. Just as it would be problematic to ask a priest to visit a hospital patient who might be Jewish (or atheist).

    What about treatments by the witch doctor (e.g. some potion)? If the tribesman wants it, and if the MD judges that it’s safe and won’t interfere with the ‘real’ treatments, it’s pretty much analogous to a patient who wants to take homeopathy in addition to his ‘real’ medicines. Depending on the circumstances, it may or may not be appropriate for the MD to tell the tribesman/patient that the potion/homeopathy is almost certainly worthless.

    What if the MD thinks the witch doctor’s potion is potentially harmful? In that case, wouldn’t he have a duty to advise against it? Just as he would have a duty to advise against going to a laetrile clinic. Ultimately, though, it’s still the tribesman’s/patient’s decision.

    Finally, I’d argue that in neither case should an MD actively solicit interventions that he knows to be useless, whether they be a witch doctor’s potions or homeopathic remedies.

    I recognize that the proper ethical course won’t always be easy or obvious. But contrary to my initial impression, I don’t think the witch doctor example reveals anything new. The only real reason I can see for treating the witch doctor/tribesman situation differently is that the tribesman’s knowledge may be more limited. This will certainly affect any efforts to advise him regarding useless or potentially harmful potions. But the same thing applies to ‘modern’ patients. They’ll tend to be more knowledgable on average than the tribesman, but it’s a difference of degree, not kind.

  3. David Gorski says:

    If an MD agreed to a tribesman’s request for a witch doctor, and the witch doctor’s role was just to assuage the tribesman’s fears, isn’t that equivalent to having the hospital chaplain stop by to comfort a seriously ill patient?

    Yes, it is.

    I don’t mean to suggest that religion is equivalent to shamanism, only that the MD is responding to the patient’s request for psycological/spiritual/cultural support from someone the patient trusts.

    Actually, religion is more or less equivalent to shamanism. Shamans derive their influence from playing, in essence, the same role as ministers or priests in their society. The key is that the patient has to request it and be of the same faith. As you point out, you wouldn’t call in a priest to minister to a Jewish patient or an atheist, nor would you call in a rabbi to minister to a Catholic. If the patient shares the shaman’s religious beliefs and views him/her as a priest in his religion, then calling in the shaman is quite equivalent to calling in a priest to comfort the patient.

  4. daijiyobu says:

    Dr. A. quoted:

    “the holistic medical movement constitutes both a deliberate attempt to substitute a magical for an engineering conception of the physical and an attack on scientific understanding and reasoning [...it's] a reactionary impetus to return the practice of medicine to the practice of magic and to replace logic and method with occultism and obfuscation.”

    I hugely agree.

    I’ve been know to say a thing or two about the irrationality of naturopathy — overall, what I call an ‘unethical sectarian pseudoscience’ — which also uses the ‘holistic’ label, and is quite a subterfuge (some new skeptical blog scribblings are here, http://naturocrit.blogspot.com/ ).

    But, what I find interesting this year as regards ‘such anachronistic irrationality’ — as relates to this specific post by Dr. A. — is that there is now a ‘holistic partnership’:

    the AANP [North American 'Federally accredited' naturopathy] has joined forces with the AHMA [American Holistic Medical Association] for their annual convention “Embody Nature / Redefine Health” (see http://www.aanp.com/).

  5. qetzal says:

    David Gorski wrote:

    Actually, religion is more or less equivalent to shamanism. Shamans derive their influence from playing, in essence, the same role as ministers or priests in their society. The key is that the patient has to request it and be of the same faith.

    Yes, that’s what I was going for – the similarity in emotional/cultural roles.

    What I didn’t want to do was offend any devout Christians, Jews, Muslims, or believers of any other religion by seeming to imply that their specific religious beliefs are no more credible than those of a primitive tribesman. (As an atheist, I don’t personally find any of those beliefs any more credible than any other, but that’s unrelated to the point I wanted to make.)

  6. vannin says:

    Thank-you for putting in the reference to psychotherapy. I think that one of the down-sides to playing shaman and giving a placebo is that true alternatives such as psychotherapy or a good exercise program are missed and the person then ends up remaining tired and dragged out rather than making the life-style changes that they need or participating in evidence-based cognitive-behavioural therapy.

  7. In 1995 I read the following article in the NY Times.
    The Experiments of Dr. Oz
    By CHIP BROWN;
    Published: July 30, 1995
    It is about Mehmet Oz, MD, a cardiac surgeon the author says is highly regarded in his field at NY’s Columbia-Presbyterian. Dr. Oz now appears frequently on Oprah. Oz brought “healers” who use a “therapy” similar to TT into the operating room to “treat” his patient during surgery. When I read this, I thought that the doctor had a lot of very frightened, nervous patients who he didn’t want to deal with so he called in the “healers” to calm them for him. Oh, how I’d love to read a follow up!

    Recently I accessed the article on the NY Times archives site and suggest that you do the same because it pertains to the discussion Drs. K & M are having here.

    Some EXCERPTS:

    At Columbia-Presbyterian the presence of hands-on healers in an operating room is only the most dramatic example of a new willingness to venture into the terra incognita of healing.

    Controversy or none, the Rosenthal center brought a lot of doctors with an interest in unorthodox therapies out of the closet, Mehmet Oz among them. In his training and skill Oz personified the prowess of Western medical science; in his experience he understood its limitations. He could sew bypass grafts and implant new hearts, but he was hard pressed to change the habits that put his patients on the operating table or to grapple with the emotional and psychological factors that might hasten their healing. Depression, for instance, has emerged as one of the major risk factors in the recovery of heart patients after surgery.

    If there were new approaches that might improve the quality of life of cardiac patients, Oz was willing to raise some eyebrows to evaluate them and do what he could to nudge a major medical center in new directions. More than willing — he felt ethically obliged.

    As Oz and others point out, many benefits arise from being able to reduce pain without medication: patients are spared side effects like constipation and stomach bleeding; they feel empowered having participated in their own recovery; they can leave the hospital sooner.

    Like all medical schools, Columbia’s is grappling with the high cost of specialized medical treatment. (This month the hospital announced that it was seeking a merger with another hospital to help ease its growing financial difficulties.) In part, this means putting more emphasis on preventive and primary-care medicine.
    END EXCERPTS

    Three things stand out to me. First, if it can be shown that something works to improve the outcome of surgery, Oz will use it without regard to why it works. Second, Oz either believes that emotional and psychological factors affect the outcome of surgery or else wants to test that hypothesis, and, third, the med. school needs money and is looking for “alternatives” to bring it in. That means pleasing customers.

  8. Harriet Hall says:

    The book “Hands of Life” describes how intuitive energy healer Julie Motz was accepted into Dr. Oz’s operating rooms as part of his cardiac surgery team.

    I’m not aware that Oz has even “tried” to do any controlled studies to show whether these alleged effects are real.

    I lost all respect for Oz when he fell for an old carnival trick and suggested that John of God was doing something to stimulate the pituitary when he stuck forceps up a patient’s nose. That’s anatomically impossible – there’s a layer of bone in the way.

    Someone needs to investigate these psychological factors, but a gullible believer in woo like Dr. Oz is not the one to do it.

  9. Dr. A, “Those in our culture, with occasional exceptions, were not brought up to believe in “CAM.”

    No, but a huge % of those in our culture, perhaps the majority, were brought up to believe in nonsense. There is a whole segment of the media that has fed them that for decades. Some doctors who use CAM recognize this and try to use it to benefit the patient. (I am not going to get into the value or ethics of this here. I only wish to state it because I don’t think it is accurate to use a broad brush to describe all MDs who practice CAM.)

    Dr. A, “Patients are not the problem; they are, if you’ll excuse the drama, the victims.”

    I disagree. I think that it is the general public that has gotten politicians, doctors and scientific institutions to offer CAM and that it was the marketers in the dietary supplement industry that got the public to do that.

    Dr. A, “every pharmacy in Europe that advertises “Homeopathie” is committing fraud, plain and simple.”

    They are only committing fraud if they tell people that there is evidence that homeo “remedies” work or that they contain active ingredients. They can explain that they contain nothing but water, alcohol or sugar till the cows come home, but there will still be many people who will believe that they work and will want to buy them. It is like stores that sell cigarettes. Unless they tell customers that they are safe, they aren’t committing fraud.

    Dr. A, “Point 3 also brings psychotherapy to mind.”

    IMO, CAM developed because of the failure of psychotherapy or perhaps because it offered people high expectations and failed to deliver.

    Dr. A, “There are plenty of modern physicians whose patients are not disposed to look elsewhere”

    If that were true, there wouldn’t be a billion $$ supplement industry. People are self medicating.

    I am a strong believer in evidence based medicine and I have great respect for the authors on this site for their incredible knowledge, intelligence, talent and high ethical standards, but i think there is a very nasty epidemic out there called CAM affecting the majority of people in many industrialized countries. I don’t think you understand where these people are coming from or speak their language. You are very rational. You are logicians. Most people and even many MDs are not. Until you understand the general public and speak their language you will not be able to educate them or do much to stop CAM from taking over the world. You will only be talking to each other.

  10. Dr. Hall, “Someone needs to investigate these psychological factors, but a gullible believer in woo like Dr. Oz is not the one to do it.”

    I know nothing about Oz. I do not know if he believes in the nonsense as Motz does or if he feels it relieves depression in specific patients and hopes that that will improve their surgical outcomes.

    If I were he, my greatest concern would be that rational patients would think that he was as wacky as Motz sounds.

  11. I assume that homeopathy is traditional in many European countries like Germany, France, Belgium and England where even the Queen is said to carry her little black box of homeo “remedies” when she travels. Peter? Ama? (Although I’ve lived in Italy, Spain and German, I never remember going into a pharmacy in Europe.) If homeo “remedies” are traditional there, I assume the public knows the theory behind them. In the US almost no one heard of homeopathy until a few years ago and very few now know the theories behind it. Most people believe that Americans are over regulated so that when homeo products are sold in pharmacies and stores next to the OTCs, they assume they are the same when that isn’t true. That is deceptive and since there is not a tradition of use here, I doubt that many in the general public would buy them if they knew the truth about them.

    If a surgeon doing a high risk operation suspects that having a wacky woman wave her hands over the patient during the proceedure will calm the patient and seriously decrease the amount of depression she experiences afterwards, something he suspects will improve her chances of a good outcome, and invites the wacky woman to proceed, is that very different than a doctor at his wits end with a seriously ill person trying something he believes can’t possibly help, but using it because he has heard stories that it does? Is it very different than the surgeon who in 1984 tried very hard to talk me into agreeing to have a masectomy to treat stage 1 breast CA because in spite of the big study just published showing that a lumpectomy and radiation are just as effective, he couldn’t believe it yet and wanted more studies to confirm that at least in his own mind?

    I’m not excusing surgeons for asking a person to perform “healing touch” or anything so silly and implausible on a patient. All I’m trying to do is point out that the picture is much bigger than “woo” and that the danger of snake oil is far greater than accepting irrational beliefs. We have to know why people are using silly therapies and the reasons are many. They include fraud, ignorance and desperation as well as a love and belief in magic and an inability to face reality. If you think CAM is only about woo, IMO you are very wrong, and you won’t be able to do a lot to combat quackery and snake oil because very few people besides Skeptics will listen to you. If you don’t care, if it really is woo that you want to focus on, that is your privilege, but I personally am concerned about the bigger picture, about nonsense being served up and charged for in scientific institutions as if it were supported by solid evidence as well as about the terrific harm snake oil does to real people. As far as I’m concerned people and doctors can do what they want to themselves and consenting adults but they have to be honest about it. What bothers me is the fraud used to sell it and I think that focusing on that we can help a lot of people. To each his own.

  12. Dr. Moran’s hypothetical about witch doctors struck me as provocative, but after further consideration, I’m not sure it teaches us anything new.

    I agree.

    Rosemary,

    I’m not quite sure what you are saying. Some of it seems contradictory. In places it seems that you can’t take “yes” for an answer. I’ll try to answer some of your points.

    Three things stand out to me. First, if it can be shown that something works to improve the outcome of surgery, Oz will use it without regard to why it works. Second, Oz either believes that emotional and psychological factors affect the outcome of surgery or else wants to test that hypothesis, and, third, the med. school needs money and is looking for “alternatives” to bring it in. That means pleasing customers.”

    So are you fer it er agin it? Sure, on its face it makes sense to use something that works without regard to why it works, but that’s a deceptive way to look at what Oz, an enthusiastic big kid with a solid background in cardiac surgery but none in critical thinking, is doing: “return[ing] the practice of medicine to the practice of magic and…replac[ing] logic and method with occultism and obfuscation.” If he wants to test the hypothesis that emotional and psychological factors affect the outcome of surgery, then he should test that hypothesis, not bring a ditzy magical thinker into the operating room to violate the privacy of the patient and to distract and embarrass the many other practitioners involved (if I were an anesthesiologist in such a situation, I’d refuse if asked and I’d be livid if I hadn’t been asked). I hope we agree that “pleasing customers” isn’t a valid reason for violating medical ethics.

    No, but a huge % of those in our culture, perhaps the majority, were brought up to believe in nonsense. There is a whole segment of the media that has fed them that for decades. Some doctors who use CAM recognize this and try to use it to benefit the patient. (I am not going to get into the value or ethics of this here. I only wish to state it because I don’t think it is accurate to use a broad brush to describe all MDs who practice CAM.)”

    Rosemary, this is exactly what my last 3 posts have been about. What “broad brush”?

    Dr. A, “Patients are not the problem; they are, if you’ll excuse the drama, the victims.”

    I disagree. I think that it is the general public that has gotten politicians, doctors and scientific institutions to offer CAM and that it was the marketers in the dietary supplement industry that got the public to do that.”

    But Rosemary, you yourself are an example of a patient who was a victim! By your own description, there was no “dietary supplement industry” as it now exists when your doctor treated you with silver. Sure, there is one now, and it’s undoubtedly an important part of the problem of irrational medical claims, but it’s not the only part and it’s not the part that I, for one, either know much about or can do much about. I know a lot about the claims themselves, about how to evaluate them, and about medical ethics and professionalism and what it takes to maintain them in the face of contradicting pressures. That’s why I write what I write; I, like every other activist, make the contribution that I’m good at making.

    The “general public” is not synonymous with “patients,” even if the latter are drawn from the former, but even if patients are victimized by themselves, it’s still up to an ethical physician to point that out.

    Dr. A, “every pharmacy in Europe that advertises “Homeopathie” is committing fraud, plain and simple.

    They are only committing fraud if they tell people that there is evidence that homeo “remedies” work or that they contain active ingredients. They can explain that they contain nothing but water, alcohol or sugar till the cows come home, but there will still be many people who will believe that they work and will want to buy them. It is like stores that sell cigarettes. Unless they tell customers that they are safe, they aren’t committing fraud.

    No. The “Homeopathie” in the window is a de facto claim about efficacy. Nor do the stores explain anything, at least in writing, about the “remedies” containing nothing. Pharmacies selling cigarettes perhaps should be embarrassing to pharmacists, but at least every customer knows what they are. Not so with homeo.

    “Dr. A, “Point 3 also brings psychotherapy to mind.”

    IMO, CAM developed because of the failure of psychotherapy or perhaps because it offered people high expectations and failed to deliver.”

    Maybe so, but what’s your point?

    “Dr. A, “There are plenty of modern physicians whose patients are not disposed to look elsewhere”

    If that were true, there wouldn’t be a billion $$ supplement industry. People are self medicating.”

    A nonsequitur. There could be one person spending billions on supplements or billions each spending 1 dollar. The truth is obviously somewhere in between, but that doesn’t refute my assertion.

    I agree with you that there is “a very nasty epidemic out there called CAM.” That is the whole point of these posts, and why I disagree with Dr. Moran that even a little “CAM” is harmless. I don’t agree that “CAM” affects the majority of people in the sense that they are using “CAM” treatments. I do agree in the sense that it squanders public money, dupes medical students, perverts the public perception of science and medicine, etc.

    “If I were he, my greatest concern would be that rational patients would think that he was as wacky as Motz sounds.”

    Precisely one of the points I made in the post.

    More later.

  13. pmoran says:

    “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. “:-)

    In an equally joshing vein, it is not yet clear to the devil’s advocate that he is entirely on the wrong track. Perhaps it is those who think medicine is collapsing into a sea of “woo” despite their best efforts so far who should be rechecking whether their understanding of the world of medicine is anything more than an adequate first approximation.

    More later.

  14. Dr. Atwood, perhaps I sound contradictory because you see things as black or white and I see several shades of gray in between.

    Am I for or against Oz bringing a “healer” into the OR? If I were the patient, I’d be angry as a hornet if he even suggested such a thing. However, I cannot judge what he did without knowing why he did it.

    You said, “If he wants to test the hypothesis that emotional and psychological factors affect the outcome of surgery, then he should test that hypothesis, not bring a ditzy magical thinker into the operating room to violate the privacy of the patient…”

    First, if the article reported correctly, the patient was very pleased with the “ditzy magical thinker”. Second, I think that if Oz is the talented surgeon claimed and if he enjoys doing surgery, that that is what he should do. I don’t think he should be asked to do research certainly not on the outcomes of psychological interventions.

    Because many patients become the victims of quackery does not negate the fact that the epidemic of CAM we are now experiencing started with the general public and worked its way up to scientific institutions. And please remember that many victims of quackery were not injured by bad practitioners of scientific medicine. Many were injured by supplements they bought after reading fraudulent ads.

    Of course I agree that “pleasing customers” is not a reason to deceive patients. However, I also believe that to refuse to acknolwedge and appreciate the huge pressure put on individual practitioners and institutions by patients deceived by marketing geniuses indicates a failure to see a big aspect of the problem. It keeps you from understanding the depth of the problem and all the forces involved.

    When i speak of your broad brush, I am referring to “woo”. Am I misunderstanding what you say? Everything I hear you and several of your colleagues say sounds like you are horrified by woo and think that CAM = woo, that CAM is caused by woo and that if only all MDs were “critical thinkers” woo would vanish at least from scientific institutions. If that is what you think, I believe it is very simplistic and inaccurate. I think that in addition to irrational beliefs there are psychological, emotional and financial reasons why patients and MDs resort to unscientific medicine.

    You state, “The “Homeopathie” in the window is a de facto claim about efficacy.” Do you actually know this is true in the various European cultures Dr. Moran referred to?

    My point about the failure of psychotherapy is that human beings have emotional and psychological needs that aren’t being met in today’s society although I don’t really know that they were ever met and I certainly don’t think that we should expect medicine to meet those needs, but i do think we should expect practitioners of scientific medicine to realize that humans have emotional and psychological needs, many of which are not being met. I realize that that may sound contradictory to you, but it isn’t to me.

    I don’t believe in God and assume that most of you don’t either. But surely you can understand how emotionally comforting it must be for people, especially terminally ill people and their loved ones, to believe they are going to “heaven” forever. I think for many people living today psychotherapy replaced religion but it didn’t help many with their psychological and emotional needs and now many are looking to medicine to do that, and of course, they will be disappointed again.

    All the studies I’ve seen show that a huge number of people is spending a huge amount of money on supplements which they believe or hope offer health benefits. Perhaps in the rarifed air of Aristotlian (sp?) logic one cannot conclude that that means that they are taking advise about medicine from people other than their physicians and leaving out their MDs, but I think that if anyone did a serious study, they would find that that is exactly what it indicates.

    If you are saying that you don’t think that the majority of people are using CAM treatments, are you saying that you don’t consider “dietary supplements” CAM? As I’ve said repeatedly, supplements are the fuel that runs the entire alt. industry.

  15. Rosemary, here are more responses:

    All I’m trying to do is point out that the picture is much bigger than “woo” and that the danger of snake oil is far greater than accepting irrational beliefs.

    I agree. That’s why I write what I write here. I do not write about religious beliefs, for example.

    We have to know why people are using silly therapies…

    Do we? Would that really help in the near future? It would be nice to be able to convince large numbers of people to stop using silly therapies, but that’s a tall order. Much taller than trying to convince modern physicians to stop encouraging the use of silly therapies. Modern physicians, unlike people in general, have an ethical and scientific mandate to act rationally. From Glymour and Stalker:

    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.

    Back to you, R:

    …and the reasons are many. They include fraud, ignorance and desperation as well as a love and belief in magic and an inability to face reality.

    I agree completely.

    If you think CAM is only about woo, IMO you are very wrong, and you won’t be able to do a lot to combat quackery and snake oil because very few people besides Skeptics will listen to you.

    I’m not sure what you mean by this. I don’t think that “CAM” is only about woo; I think that “CAM” is woo.

    If you don’t care, if it really is woo that you want to focus on, that is your privilege, but I personally am concerned about the bigger picture, about nonsense being served up and charged for in scientific institutions as if it were supported by solid evidence as well as about the terrific harm snake oil does to real people.

    So am I, as I’ve written countless times. It’s the scientific institutions (and medical schools and governmental endorsements) that I’m after.

    As far as I’m concerned people and doctors can do what they want to themselves and consenting adults but they have to be honest about it.

    I agree that people can do what they want. Doctors cannot do what they want. Doctors must be honest. Doctors who push “CAM” are not honest.

    What bothers me is the fraud used to sell it and I think that focusing on that we can help a lot of people.

    Isn’t that what we’re focusing on here?

  16. Dr. Atwood, “But Rosemary, you yourself are an example of a patient who was a victim!”

    I was not the victim of the MD. I was the victim of the drug company that published fraudulent ads. I don’t feel I can judge the doctor with today’s yardstick. He was definitely naive in that he believed the ads in an era when drug companies were not strictly regulated, but according to my definition, he was not a quack. He did not sell the drug he prescribed. My mother bought it at the pharmacy. The claims were not irrational. They were fraudulent. I was born in 1942 and have articles from med journals older than I am lying about the safety and efficacy of silver drugs, articles older than I am warning doctors about the fraud and fraudulent ads older than I am.

    Dr. A, “By your own description, there was no “dietary supplement industry” as it now exists when your doctor treated you with silver. Sure, there is one now, and it’s undoubtedly an important part of the problem of irrational medical claims, but it’s not the only part and it’s not the part that I, for one, either know much about or can do much about.”

    Supplements are not the only part of CAM but they are the common denominator, the fuel that runs the industry, the billion $$ money maker. Irrational beliefs are easy to target. False information requires a lot of investigation. Supplement promoters, especially botanical promoters, are often brilliant, rational and know some science. They cut and paste bad study after bad study showing efficacy and tear apart good ones showing none and laugh all the way to the bank which is exactly what they are paid to do, deceive people to make money.

    Far more people are concerned about and can recognize fraud than irrational beliefs. If you limit your exposes to irrational beliefs you will have a much narrower audience and much smaller impact than if you expose fraud. IMO, the only way that we can really have a major impact and protect the public is to have many people actually learn enough about supplements to recognize fraud when it occurs and expose it.

  17. Rosemary,

    First, excuse me for not having read your latest comment before posting my own. I had to write mine piecemeal, and couldn’t look to see if you had answered without losing mine.

    It seems that your argument, distilled, is that it’s the dietary supplement industry, with its advertising and its financial incentives to pushers, that is at the bottom of the current “CAM” fad. By not addressing that, you argue, we SBMers don’t have a chance to make much difference. No?

    I agree that this is an important issue. It is far from the only one. There are numerous quackademics at prestigious medical schools and elsewhere whose original motivations had nothing to do with dietary supplements, although in some cases those became part of their “programs” later, for obvious reasons. Examples: here, here, and here. There are others who have pushed “CAM” drugs that are not “supplements” and that have no financial backing or marketing efforts by their manufacturers. A huge example, which is the basis for several of the most pernicious organizations of “CAM” physicians and of the most expensive and largest trial yet funded by the NCCAM, is discussed at length here.

    I have already written in opposition to practitioners pushing “natural remedies” or drugs of whatever ilk. Some of us (not me, because I find it boring) have written in opposition to the 1994 DSHEA law, which as you know opened the marketing floodgates for “supplements.” It would be great if that law were repealed, and I’m sure we’d all be for it.

    It might even happen. If Congress is actually successful in giving the FDA the power to regulate tobacco (a terrible idea, in my opinion, but for reasons that have nothing to do with this discussion), “supplement” companies and advocates won’t have a leg to stand on. Sure, they have money, but so does “Big Tobacco.”

    KA

  18. Harriet Hall says:

    Rjstan said, “I don’t think he should be asked to do research certainly not on the outcomes of psychological interventions. ”

    OK, but if he’s not going to do research and is not using any control group, he has no right to make the claims he is making for the efficacy of the woo. In Julie Motz’s book she says Oz credited her with the success when a transplanted heart started beating, saying he didn’t know what she did in there, but he’d never seen a heart come back so fast. He made Motz part of his team and allowed her to introduce a macrobiotic diet, acupuncture, hypnosis, aromatherapy, changing light from fluorescent to incandescent, and cleaning the floors only with natural cleansers. He allows Motz to tell patients they are responsible for their own illness, and she makes them act out the anger and relieve emotions that were going on in their life at the time their illness began. She tells them they are bringing treatments such as surgery into their lives in order to relive their traumas, including prenatal traumas. I simply can’t believe all that is in the patients’ best interests.

    And it’s not a matter of patients asking for woo; the energy healer is officially part of Dr. Oz’s team: surely that influences patients. If you are about to have major surgery, you may acquiesce to anything you think the surgeon approves of.

  19. Harriet Hall says:

    Rjstan said, “in addition to irrational beliefs there are psychological, emotional and financial reasons why patients and MDs resort to unscientific medicine…humans have emotional and psychological needs, many of which are not being met.”

    I think we all understand that. And like Peter, I have no objection to patients using unscientific treatments as long as they can give informed consent. My objection is to lying to the patient, implying that a treatment is supported by evidence when it really isn’t. Or attributing its effects to qi, subluxations, or other mythical entities.

  20. Dr. Atwood, since i’m sure if people are reading this that I am driving them crazy, I will try hard to make this my last comment on this topic.

    You said, “I think that “CAM” is woo.” If by that you mean that you think that all CAM is irrational, you are wrong. Not all of it is. A huge part of it is fraud. I will use silver as an example. i will not pull files. I will do it from memory. (Some is on my webpage with citations.)

    When I heard that silver was being sold as a supplement, I asked the salesmen how they knew it was safe and effective. Many mentioned Henry Crookes, MD. There were ads that made it look as if he were alive and well and working today. I eventually found he was writing for journals in England and selling “collodial silver” there and in the US in the early 1900s. I located his articles that included photos of petri dishes with silver supposedly killing bacteria. There were articles praising his products in the Lancet and the British Medical J among others by several different doctors.

    JAMA called old Henry a quack in 1919. I found several articles by the agency, the name escapes me, that preceeded the FDA. They had a column in JAMA reporting their investigations and warned about Henry and his buddies and their articles several times. Yet today’s silver quacks are still citing the old quack articles.

    They also constantly quoted Robert O. Becker, MD and his popular books. I read one and it didn’t say anything about drinking silver. Eventually, I located Dr. B. He is a reputable silver researcher horrified by the way silver quacks cite his work to promote supplements. He gave up trying to stop them. He’d contact a site, they’d remove the reference and two more sites would pop up using it. He had me post a disclaimer on my site.

    I could give you many more examples, but will limit myself to one more often offered as a reference by today’s silver quacks, Robert J. Harman. I got a copy of his book which looks to me like a reputable textbook on colloid chemistry published in 1938. Hartman appears to have been a chemist at an Indiana university. His last chapter is on colloids in medicine. It contains pictures of the petri dishes that look just like those Crookes showed in his articles because they are. He credits the photos and the information to the Crookes Laboratory. Like my doctor, he believed them and never tried to verify their claims. The silver quacks quote p. 538 of Hartman’s book where he says something like silver has been found safe enough to put into the eyes and nose. On the bottom of the same page, something the silver quacks never mention, he says that colloidal lead, another Crookes product, has been successfully intecjed into cancerous tumors. (I don’t have the book opened and know I’m not getting the wording correct, but you get the idea.)

    When I tried to file a complaint with the FTC, I said to the lady, “They are quoting old quacks as if they were reputable researchers working today!” She laughed and said, “They all do that.”

    This is fraud. It is lying to make a buck. And the good quacks could easily fool the best critical thinker if he didn’t begin by checking the facts, a task that can get overwhelming very quickly and which is the main reason why the person making the claim has to substantiate it.

  21. Rosemary,

    Once again we are cross-posting, but no matter. Woo and fraud are not mutually exclusive. Almost all “dietary supplement” marketing claims are woo, in that they are not backed by anything close to reasonable evidence. Their sales are thus fraudulent. Colloidal silver, by no stretch of the imagination a dietary supplement, is also both woo and fraud. Perhaps you noticed that a few weeks ago I cited the naturopath’s bible, the Textbook of Natural Medicine (2nd edition, Pizzorno and Murray Eds, Edinburgh, Churchill Livingstone, 1999) for having plugged colloidal silver, administered orally, as a treatment for opportunistic infections in HIV+ patients (p. 1292). The basis for that recommendation was a single report of silver used as a preservative.

    That recommendation is woo, and its fulfillment would be fraud.

    KA

  22. overshoot says:

    In Julie Motz’s book she says Oz credited her with the success when a transplanted heart started beating, saying he didn’t know what she did in there, but he’d never seen a heart come back so fast. He made Motz part of his team and allowed her to introduce a macrobiotic diet, acupuncture, hypnosis, aromatherapy, changing light from fluorescent to incandescent, and cleaning the floors only with natural cleansers. He allows Motz to tell patients they are responsible for their own illness, and she makes them act out the anger and relieve emotions that were going on in their life at the time their illness began. She tells them they are bringing treatments such as surgery into their lives in order to relive their traumas, including prenatal traumas. I simply can’t believe all that is in the patients’ best interests.

    Does informed consent enter into this even peripherally? Do Dr. Oz’ patients get any say in whether they are to be (and pay for being) the subject of someone’s ritual magic?

  23. Jules says:

    I have to wonder if:

    “introduc[ing] a macrobiotic diet, acupuncture, hypnosis, aromatherapy, channging light from fluorescent to incandescent, and cleaning the floors of with only natural cleansers”

    is that bad. I mean, honestly? If you found that washing soda and water worked just as well as your average floor cleaner with seventeen chemicals (and it does–I use it on our floors), is it really that terrible to change? If having a room smell of lavender and bergamot oil makes you calm (smell is very closely tied to emotion), wouldn’t it be better than having you stressed out by the hospital environment? And light can affect a person’s mood, too.

    The rest of the stuff (the psychobabble) is pure crap. As much as I hate playing the “you’re sick because society made you sick” card, I would never tell someone that they’re sick because they somehow brought it upon themselves. They probably realize it already, and that’s just not going to help. And “prenatal trauma”? I subscribe to a lot of CAM stuff*, admittedly, but that’s going too far.

    *The CAM stuff I subscribe to is that which falls under the range of “scientifically possible, though not yet proven”. They are, mostly, the herbal medications and dietary recommendations that I’ve tried on myself and found effective, as well as yoga. I use honey instead of neosporin on my cuts, and eat a largely vegetarian diet–not because I think it’s healthier (which I do), but because I just happen to not like the taste of meat. Aromatherapy–okay, smelling nice things does make one happy, but beyond that I don’t think it’s actually effective as medicine.

    On the other hand, being happy is a MAJOR component of recovery–I’ve lapsed on my reading on how the nervous system affects the immune system, but as of 2005 (the last year that I followed this closely) the studies seemed to to be pointing towards stress actually lowering immune cell counts and other objective measurements of immune function. The science seems to be indicating that if we let patients have their way with otherwise harmless things like crystals and incense (obviously not for an asthmatic!) then they might just recover faster. I don’t know if there’s any way to make a rule on how far we should go.

  24. Am I really the only one who sees a magnitude of difference between the recommendation of the use of a supplement based on the single report of its use as a preservative and the publication of “lab” reports showing in vitro activity when there was no such activity? Am I the only one who sees how almost all MDs and educated laypeople would laugh at the first and conclude that the NDs were idiots but could possibly be fooled by the second?

    Am I the only one who thinks it is criminal, not irrational, to claim your product contains an element like silver, something so easy to know for sure, when it doesn’t?

    Am I really the only one who sees a huge difference between lying to make money, even when you know that your lie can result in harming people, and promoting nonsense that you actually truly believe in like “energy medicine” or prayer for the prevention and cure of disease?

    Am I the only one who sees a difference in the role of a prosecutor and a scientist, the FTC and the FDA?

    Am I the only one who thinks that when exposing quackery you should give a lot more weight and spend a lot more time and effort on fraudulent, made up, deliberately invented reports of benefits than on things as utterly silly as with wacky people, often very nice wacky people telling others to drink something to cure a disease like AIDS because there is one study that showed it worked as a preservative, or because the fairies told you that it worked or maybe the stars indicate that it does?

    Sorry. I know I promised to drop the subject. I’ll try again, but before I do…

    Harriet, if what you claim Motz wrote is true, my opinions of Oz would be very different. I would not give him the benefit of the doubt. I don’t have the time to investigate. If I did, I’d get a copy of Motz’s book and contact Columbia to see if her statements are true. I would also try hard to find out what Oz is doing there now and what he has done since the article I cited was published in 1995.

    What I’m trying unsuccessfully to bring out is that I feel completely disconnected with the majority of you because of your tone. I get the impression you weigh all silly, nonsense equally. I do not. I laugh at most of it, but I don’t laugh at fraud. Fraud infuriates me and I am not going to split hairs with definitions of fraud and irrational beliefs. When discussing quackery, I hate the Skeptic’s use of the word woo because I think that the people you should be trying to reach don’t understand it and when they do they will think you are talking down your noses at them. I am talking about feelings and perceptions here, things I get the impression Skeptics have difficulty dealing with, things I think have to be used to communicate with the general public.

  25. Rosemary,

    “Woo” means “bullshit.” I use “woo” as a shorthand for implausible medical claims (IMC). Perhaps I should be more formal. My writing is aimed not at every person who dabbles in “supplements,” but at People Who Should Know Better, such as some physicians, some medical school deans and other administrators, some scientists at the NIH, and some legislators. If they feel talked down to (assuming any of them even reads this stuff), that’s fine with me. They know what we mean when we write “woo,” and they ought to feel the sting of the insult. It is they who have embarrassed science and medicine, and who have violated the public trust.

    The selling of woo, whether for financial gain or not, is fraud. The intentions of the seller are irrelevant and often unknowable.

    I agree that in all contexts, some versions of fraud are more dangerous than others.

    What Harriet wrote about Motz and Oz is accurate.

    KA

  26. Hermano says:

    Dr. Moran is indeed “muy simpático”.
    I am very glad Dr. Atwood sees him as a moral compass.

  27. Hermano says:

    Rosemary,

    I understand you consider it unethical for the naturopaths to sell
    supplements to their patients.
    Are you OK with “Team Atwood” making $$HUGE$$ profits selling
    “classic” thongs all over the internet?
    http://clothing.cafepress.com/item/team-atwood-classic-thong/37826505
    $12.99 for a nickel worth of fabric.

  28. Hermano, I think it should be illegal for anyone treating patients to sell them products for which they make health claims, and I do mean anyone, MD, ND, DC, etc. I also only mean products for which they make health claims. That should answer both your questions.

  29. Zetetic says:

    Honey on cuts? Isn’t honey a potential source for botulinum spores?

  30. pmoran says:

    We have reached that point where the urge to respond to every comment can expand verbiage exponentially and tiresomely. I will try instead to move discussion on.

    The standard healthfraud position is that even if CAM may sometimes be helpful to people, it is a bad thing regarding which there can be no compromise.

    It is a bad thing because, to quote KA, “implausible claims being promoted, tacitly or otherwise” leads to ” 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.”

    Superficially this is a powerful line of argument, because we can fairly easily find instances where such predictions are fulfilled. Yet I have suggested that healthfrauders routinely exaggerate the risks of CAM, that some potential dangers are not realized much in practice, and it again needs to be said that the medical risks depend very much upon the specific “quack” claim. Also, some of these outcomes, if as truly awful as implied, may be thought of as mainly exposing a puzzling lack of reach for more rational voices. This is the very reason why I have an interest in examining the kind of messages we are putting out.

    And there is considerable evidence against some of the above. Surveys routinely show that the majority of CAM-using patients express great satisfaction with them. Despite this, nearly all also use conventional methods, and are satisfied with that. Even in this heyday of CAM, very few of the public use CAM exclusively.

    The Scots are an interesting case study. They don’t seem to be vastly worse off health-wise or science-wise, or even exceptionally befuddled, yet 50% of their doctors prescribe homeopathic remedies and a further 10% use herbs. http://www.scienceagogo.com/news/20061027232826data_trunc_sys.shtml .

    What this adds up to is that the public may not be (generally) as indiscriminate in their use of alternative methods and as in need of protection from unscientific concepts as we healthfrauders like to think. Maybe we skeptics encounter a disproportionate amount of the dangerous and nutty extremes of “alternative” medicine because we go looking for it and we hang about on forums that gather it. We are also fairly obviously more deeply offended by it than most, which can lead to confirmation bias.

    Which brings me to this: in science-based medicine we are quite accustomed to evaluating medical options in terms of benefits vs risks. We normally try to quantify them so that we can reach a reasonable balance. An example is studies designed to determine the optimum dose of a noxious chemotherapeutic agent, so that cancer remissions are produced at acceptable risk. These days such studies even often include quality-adjusted life year (QALY) measurements so that all aspects of patient life can bear upon a precise, measurement-based, final judgment.

    That’s how we normally operate. Not so, apparently, when it comes to CAM.. In relation to that we adopt the meanest, least flexible possible position, even while lacking any clear evidence-based handle on the medical or psychosocial benefits or the social functions of unconventional and folk medical activity, or their risks. All we know, having completely dismissed all the anecdotal evidence, is that they usually don’t work obviously better than placebo when put to the test in the banal environment of the typical controlled trial. We don’t care that they may be being used mainly when there is no entirely satisfactory evidence-based treatments for the complaint, nor that some of the methods may simply have not yet been subjected to sufficient study to be quite sure whether they have intrinsic medical activity or not. It’s all one, if it is seen to be “alternative”.

    Is the resort to ethical argument about the use of placebo medicines a lazy way of justifying such a globally rigid approach? The ethical card has some force, even when set against other primary ethical obligations of doctors towards their patients, but in reality it can only apply to that select few who have a clear enough grasp of the scientific evidence to be as certain as can be that any given CAM treatment IS a placebo. But Healthfraud has to also deal with what a lot of other practitioners think and what our patients are often trying out on their own initiative. It is a waste of time talking ethics to those who don’t share quite the same scientific convictions, and that applies to almost everyone.

    KA seems to help my argument with personal medical experiences that are reminiscent of some of stories of “alternative” testimonial. I was quite struck by them, for I have had very similar personal experiences and observed them in many patients. They illustrate how there can be a complete disconnection between the benefits of medical interactions and their scientific content, and, indeed. any treatment content .

    We have no basis on which to assume that similar benefits are not regularly occurring within CAM, especially when a lot of people are telling us so. In fact, KA elsewhere is arguing the reverse, that while CAM may be offering placebo and other non-specific medical benefits these can equally well occur within the 5-15 minute hurly-burly of the typical present day medical practice, I am sure they can, with good doctors, but I would love to be quite sure about the “equally”. Depending on the condition, and with as much reluctance and regret as anyone here, my money would be on the practitioner who is not hamstrung by what science says, and in consequence has a confident explanation for everything and never runs out of remedies. Sure, some of his clients may eventually realize that he is actually a nutcase, but even most of those will probably find ways in which they think he has helped them.

    The reason I am being a bit stubborn about these matters is that I have what is as yet merely a vague inkling that they are important — that they may, despite initial appearances, help rather than damage our purposes.

    Those who we might wish to influence in various ways may not have sufficient familiarity with science and medicine to be able to articulate the line of argument I am developing (it is difficult enough for me and I know I have a long haul ahead of me even if I am entirely right), but one of the reasons for our distressing inability to have the influence we desire may well be that people of ordinary intelligence and experience can nevertheless almost instinctively sense the weaknesses and exaggerations in some of our habitual arguments. They switch off. We may be able to do better with a change of tack if that that might actually be more in touch with medical realities.

    Be reassured that looking at CAM methods in strict cost/risk/benefit terms will definitely not change most of our judgments concerning CAM. The main difference would be in the emphasis of argument and some of the rhetoric. We would still be able to describe Hulda Clark as a dangerous and severely deluded cancer quack, or, if you prefer, an unspeakable criminal fraud.

  31. l_s_olabisi says:

    While I appreciate this thoughtful discussion (and the website in general), I must take issue with the adjective “primitive” as used to describe a hypothetical patient with shamanistic beliefs. I believe this word was intended to describe a person not educated in ‘Western’ science or medicine, and the challenges involved in communicating with such a person might certainly be daunting. However, many shamanistic cultures have incredibly complex social networks and family structures (for example) that are by no means ‘primitive’. Please find a different, less perjorative word to describe other cultures!

  32. pmoran says:

    I’ll try and find a better word than “primitive” but just about any word I can think of seems likely to be regarded as pejorative by those who see much to prize in the medical beliefs of ancient cultures.

    While on this subject, why do you use the word “Western” to distinguish science-and-technology-based medicine from that built upon religion or old superstitions? That expression clearly originated as an attempt to bring an extremely effective approach to medicine down to the same level as a pack of others that have been tried throughout the history of mankind.

  33. l_s_olabisi says:

    For Dr. Moran and others, let me clarify my remark. I was objecting to the use of the term ‘primitive’ to refer to a *person* (the hypothetical tribesman, in this case), rather than to a belief. I suppose that describing someone’s lack of knowledge of science-based medicine, or belief in shamanism, as ‘primitive’ might be acceptable, although I still think a better choice of words might be ‘non-scientific belief system’ or some such, as clunky as that is. I hope you’ll agree with me that describing a person as ‘primitive’ (or ‘advanced’, for that matter) is not a medical or scientific judgment, but a value judgment.
    I agree that describing science-based medicine as ‘Western’ was poor phrasing; it was force of habit on my part (although I was unaware that others have used this phrase to denigrate the scientific approach to medicine).

  34. How about pre-scientific medicine? If that is too clumsy, I have no problem with primitive medicine. The reason is that it really doesn’t discriminate if you remember that till not much more than 100 years ago everyone including all the ancestors of everyone living today used primitive or pre-scientific medicine and crude non-standardized remedies, some of which were utterly useless, some dangerous and some just very unreliable.

    Presently, scientific medicine is used by all major and probably most minor cultures. While it may have started in Europe, the benefits of scientific medicine were quickly realized by people all over the world. I suspect that if you look at the names of the researchers in most major scientific institutions and journals, you will find that a great many come from non-western cultures.

    I use the term “unscientific medicine” for what is presently often called alternative, holistic, natural, integrative or complementary. Ironically enough unscientific medicine originated or at least entered its Golden Age in Europe and English speaking countries although proponents of unscientific medicine sometimes seem to like to think that it is a reincarnation of primitive medicine. IMO, it is more like a belief in the myth of the “good old days” when everything was simple and wonderful.

    Proponents of unscientific medicine often erroneously claim that scientific medicine is based on a system of cultural beliefs held by arrogant, nasty, prejudiced, Euro-centric, white men who favor white coats, ties and stethoscopes. To help convey that picture to the general public they sometimes call scientific medicine Western medicine. IMO, claiming that scientific medicine is the sole province of white males and the West is about as prejudiced as you can get since it implies that the rest of us are too dumb to recognize and embrace the great benefits scientific medicine has offered the world and the great promise it still offers it.

  35. durvit says:

    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.

    Dr Ben Goldacre’s placebo series on BBC Radio 4, part 2 and part 1 touched on this issue but didn’t explore it. Many of the commenters enthused about the possibilities of placebo but demurred at the ethics of using it. Plus, there was the usual strand that considered whether the placebo response of CAM might justify its use if it might be implemented in an ethical manner. There was no discussion as to whether this might be a gateway for introducing an acceptance of ‘magic’ or woo in medicine, and how we might establish the firm boundaries around when it might be appropriate or not.

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