My Discussion with Dr. P
After last week’s post, Dr. Peter Moran answered with more salient points. I’ll spend this week discussing those, because I share Dr. Moran’s “interest in examining the kind of messages we are putting out.” Acknowledging the inequality inherent in his not being the blog author, I’ll offer the last word to Dr. Moran by ending this series* and letting whatever comments he may have in response to today’s post be the last, at least for now.
Here is Dr. Moran’s response to my response:
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,” [and more].
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.
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 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.
My Response to His Response to My Response
Let me say, again, that I am not trying to prohibit free citizens from pursuing whatever “CAM” they feel like pursuing. What I’m against is physicians violating their own ethical mandates, and governments and medical schools tacitly or explicitly promoting pseudomedicine. If 50% of Scots use homeopathy, so be it, even if it illustrates a deficit of science education in Scotland (I agree that “some of these outcomes…may be thought of as mainly exposing a puzzling lack of reach for more rational voices.” We’ve discussed that before: it argues for a better reach for rational voices, not for rational voices condoning the irrational). If “50% of [Scottish] doctors prescribe homeopathic remedies,” that is a different and real problem, both for medical ethics and for the regulation of physicians in Scotland. If Scots are not ”vastly worse off health-wise,” that is a triumph of modern public health and scientific medicine in spite of homeopathy, not because of it. Scots are obviously worse off “science-wise” for homeopathy, whether or not this has been measured, just as Americans would be worse off science-wise if “intelligent design” advocates had their way.
Yes, “we can fairly easily find instances where such [dire] predictions are fulfilled.” We on SBM have written about many of them. How many such instances does it take to counteract the (possibly) many more instances of patients expressing “great satisfaction” with “CAM”? Very few, it seems to me. I think that the public is in need of protection from unscientific concepts, both because some people are not as capable of discriminating as others, and for the larger societal reasons listed above. Even if that were not the case, my point in these posts is that physicians ought not to be dishonest. The border between what a physician can and cannot ethically recommend must be the point at which honesty and integrity are compromised, not the point at which some arbitrary distinction is made between “safe” and unsafe implausible treatments—even if pseudoscience might make some patients feel better.
A regular column in the New York Times Magazine is “The Ethicist,” by Randy Cohen. Readers send real examples of ethical dilemmas for commentary by Mr. Cohen, who is very good at providing it. The July 27th issue included a non-medical illustration that “little white lies” are not the best policy:
By RANDY COHEN
Published: July 27, 2008
A friend, a nonwriter, retired after a distinguished career, asked me to read his screenplay because I am a published author. It was terrible: poorly written with no plot. Worse, it was clearly autobiographical, abounding in self-aggrandizement and intimate sexual details. To be kind, I told him merely that it was too personal. Recently he met a literary agent. I fear he will share this document with the agent and be humiliated. Must I now tell him my full opinion? — NAME WITHHELD, ARIZONA
If we rejected every work of fiction marred by vanity or cringe-worthy self-exposure, miles of shelf space would be left vacant at Barnes & Noble. And as a commercial matter, it is curious to discourage your friend from writing about himself in an era when memoirs proliferate like kudzu, which had sex with some other kudzu, to which it was not married. But it is in neither your literary judgment nor your commercial savvy that you most failed your friend — and fail him you did — but in your lack of candor. If he requested your honest opinion (and not just praise, another possibility), you should have provided it, as gently as possible. To be misleading is not to be kind.
It’s no picnic telling a friend that you don’t think much of his work, but you agreed to give him your professional assessment, and that’s what you should have done…
To be fair, I make the following disclosure. I asked Mr. Cohen’s permission to include that quotation in this blog, briefly suggesting to him how I would use it. He kindly gave his permission, but with this caveat:
I’m not sure I agree that the editor-writer relationship is analogous to the doctor-patient relationship, and I should also mention that many people—many writers—disagree with me here. Several said they’d absolutely lie to a non-writer friend who sought their opinion; they’d cosset the non-writer with praise.
I think that Mr. Cohen should give himself more credit. If anything, the doctor-patient relationship requires more ethical rigor, as it were, than does an informal interaction in the “outside world.” What many writers say they would do, moreover, is only barely relevant to the ethics of the situation. I agree that “to be misleading is not to be kind,” and also that there is a gentle, constructive way to be honest in such situations. That applies to writers talking to non-writers and to physicians talking to patients.
Back to Dr. Moran. I’m not sure I understand his point about “quality-adjusted life year (QALY) measurements.” How can chemotherapy, a rational treatment whose effects, both good and bad, are well documented, be compared to “balancing qi”? We know a lot about implausible treatments. We know that they are implausible. We need to know about their “social functions” as much or as little as we need to know about the social functions of our patients’ religious beliefs. Sometimes that may be considerable (as in Dr. Moran’s previous example of the witch doctor), other times not at all, but never does it mean that we ought to promote such social functions—any more than we would promote religious beliefs.
“CAM” is not necessarily “all one, if it is seen to be ‘alternative’.” The occasional “CAM” treatments that are plausible—some molecules, mainly—deserve the same consideration from physicians as do plausible new drugs that have not yet been approved for general use: we should favor appropriate investigations but not premature recommendations, except in extraordinary circumstances. Other treatments that are typically labeled “CAM” but are not, such as relaxation, exercise, some diets, and some manual therapies, are perfectly rational and are not at issue here.
Was Dr. Moran referring to physicians when he wrote of the “select few who have a clear enough grasp of the scientific evidence…”? If so, that is a sad commentary on recent medical training. It also may reflect a little-appreciated deficiency of Evidence-Based Medicine, i.e., its failure to acknowledge the necessity of scientific plausibility. Regarding the charge that to “resort to ethical argument about the use of placebo medicines” is “lazy,” I think that in the current cultural environment, the easier and therefore lazier stance for physicians is to acquiesce to the “CAM” fad (just as to “cosset the non-writer with praise” is the lazier stance for writers). This is evidenced by the widespread encroachment of “CAM” onto medical school campuses and the almost complete lack of formal opposition.
Regarding the “placebo effects” that I reported having experienced (my “personal medical experiences”), I don’t see how those help Dr. Moran’s argument. The whole point of those experiences was that they occurred in the context of rational medicine. I don’t see any “disconnection between the benefits of medical interactions and their scientific content” in those experiences. On the contrary, it was the rational content of the information that I got from those interactions that made me feel better. Even if other people might get similar comfort from irrational content, so what? I have not denied that in any of these discussions; I have argued that physicians ought not to steer patients in that direction by subterfuge or ignorance, and that rational medicine has a similar, if sometimes unrealized capacity for comforting patients.
Dr. Moran’s next paragraph is the most troublesome. He surely knows that impugning the “5-15 minute hurly-burly of the typical present day medical practice” can only be an argument for changing the way present day medicine is practiced, not an argument for “CAM.” Regarding non-specific medical benefits that might accrue from “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,” what is new or worthy about that? It’s a perfect description of the classical quack. It is remiscent of a passage quoted previously on SBM, whose very authors appeared to have missed the point:
Chiropractic finds its voice exactly where biomedicine becomes inarticulate. Too often, biomedicine fails to affirm a patient’s chronic pain. Patients think their experience is brushed aside by a physician who treats it as unjustified, unfounded, or annoying, attitudes that heighten a patient’s anguish and intensify suffering. Chiropractors never have to put a patient’s pain in the category of the “mind.” They never fail to find a problem. By rooting pain in a clear physical cause, chiropractic validates the patient’s experience.
Should MDs aspire to similar, deceptive practices, merely because they “validate the patient’s experience”? I’m sure Dr. Moran will agree that the passage does not constitute an argument for that. All it does is portray chiropractors as sleazy salesmen.
If rational medical practitioners need “a change of tack that might actually be more in touch with medical realities,” such a change might include offering patients more time, better explanations, more honesty, more sympathy, and a more creative range of rational treatments. All of Dr. Moran’s points argue for those. None argues for “CAM.”
KA will be on vacation next week.
* 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