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What’s The Harm?

Any promoter of science-based medicine often faces the question – what’s the harm? What is the harm if people try treatment modalities that are not based upon good science, that are anecdotal, or provide only a placebo benefit? There are generally two premises to this question. The first is that most “alternative” placebo interventions are directly harmless. The second is that direct harm is the only type worth considering. Both of these premises are wrong.

The pages of SBM are filled with accounts of direct harm from unscientific treatments: argyria from colloidal silver, death from chelation therapy, infection or other complications from acupuncture, burns from ear candling, stroke from chiropractic neck manipulation – the list goes on. You can read anecdotal accounts of such harm on the website, whatstheharm.net. Of course, as we often point out, harm and risk is only one end of the equation – one must also consider benefit. It is the risk/benefit ratio of an intervention that is important. But generally we are talking about interventions that lack any evidence for benefit, and therefore any risk of harm is arguably unacceptable.

But perhaps the far greater harm comes from indirect causes. I was reminded of this with the publication of a study looking at flu vaccine uptake in 9 countries. They found that among older individuals who did not get the flu vaccine there was an increase in negative attitudes toward the vaccine, but also there was an increase in the use of traditional unscientific interventions. Cause and effect here is likely to be complicated. People who rely upon folk remedies may feel that they do not need the flu vaccine. Also, those who do not trust in the vaccine may then seek out alternatives. It is likely also true that the subculture of “alternative” medicine simultaneously fosters both a belief in unscientific treatments and a mistrust of mainstream science-based interventions.

The study authors conclude:

The hypothetical framework can be used to guide healthcare providers in developing strategies to foster normative beliefs of older people in vaccination, provide effective action cues and promote vaccine access.

“Normative beliefs” is a technical way of referring to the fact that promoters of “alternative” modalities tend to foster bizarre and unscientific beliefs in the public. Dubious treatments are often marketed with false notions about biology, physiology, and anatomy. It turns out, the iris of the eyes do not contain a functional map of the body (nor does the bottom of the foot). There is no human energy field or biofield or chi. Acupuncture points have no basis in reality. Magnets do not attract the iron in our blood. And toxins do not build up in our tissues, causing most diseases.

The consequences of fostering incorrect notions about human physiology and the nature of health and disease are difficult to measure or quantify, but they should not be ignored as a significant source of indirect harm from unscientific treatments.

The marketing of unscientific treatments often involves warning potential customers away from mainstream medicine, or at least downplaying the effectiveness of science-based treatments or overstating their risks. One does not have to look beyond any pro-CAM website to see articles scaring the public off science-based treatments side by side with advertisements for unscientific alternatives. The internet is unfortunately full of commercialized websites working directly against efforts to create “normative beliefs” in the public.

Belief in ineffective treatments and mistrust of science-based treatments may lead to delay in effective treatment and worse outcomes. In addition they create financial harm, which is increasingly important as health care costs rise. Financial harm can be extreme in cases of the desperation caused by serious illnesses. Tens of thousands of dollars are spent, for example, to send one patient to a fraudulent stem cell clinic. This financial harm is not limited to the patient or their family, as often such treatments are funded by charity from extended family, friends, and colleagues.

There is further psychological harm from creating false hope. I have personally seen the crushing effects such false hope can create when reality finally sets in. This can also significantly delay the process of psychologically dealing with a serious illness, which further affects important decision making about care. Wasting time on worthless treatments can also rob the terminally ill of precious time spent with loved-ones.

Further, the allure of unrealistic treatments diverts scarce resources (hospital space, research time and money) away from more fruitful modalities.

Conclusion

The ripple effect of harm that flows from unscientific medical beliefs is multifarious and significant, but often neglected by those who are not familiar with the phenomenon. “What’s the harm” is therefore a question we will have to answer frequently and for the foreseeable future.

Posted in: Public Health, Science and Medicine

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20 thoughts on “What’s The Harm?

  1. MKirschMD says:

    Many ordinary folks wrongly feel that a test or treatment is safe, if there is no risk of direct injury. This belief partly explains the public’s appetite for CAT scans and total body scans (scams?), as the consumer cannot appreciate the potential indirect harm. These scans identify ‘abnormalities’ in various organs that are clinically meaningless, and then generate anxiety and a cascade of medical testing that may last months or longer. So, your point is not restricted simply to quackomedicine. Indirect harm exists in conventional medicine also.

  2. windriven says:

    A hoary adage holds that one can lead a horse to water but one can’t make it drink. Some people are absolutely resistant to rational thought preferring instead the land of make-believe where all things are possible.

    It is clear that vaccine denialism results in significant public harm. It is also clear that children are not playthings with which their parents might dabble in mystical healing. Other cases can be made where personal sCAM choices impact public health (venereal diseases, tuberculosis, etc.). There should be no wiggle room in any of these situations.

    But when Aunt Mary wants to treat her lung cancer with jimsonweed tea, I say: go for it. But sign off on publicly funded scientific medical care when you do; no going back. In the first place it would be ethically difficult to force a sane (?) adult to endure therapies s/he doesn’t want. In the second place there is broad instructional value to the rest of the herd when these alternative therapies fail.

    I do not mean this to sound cold or unfeeling. Every effort should be made to educate. But choices have consequences.

  3. krelnik says:

    Thanks for the nice plug!

    Aside from my site What’s The Harm, folks can get regular doses of similar stories by following me on Twitter, Facebook or Friendfeed under the name KRELNIK. I also post a “this day in skeptic history” every single day.

    Cheers!

  4. kurofune says:

    The commentary on normative beliefs is interesting, especially because it seems that use of ‘alternative’ medicine makes one less likely to seek the aid of rational medicine.

    While this argument certainly responds to the soft-minded “what’s the harm” defense, I’m more convinced by a simpler problem: opportunity cost.

    Economically, resources are always scarce in some way be that cash or the fact that most people only have the energy for a single modality. While I think that the normative effect described above does play a role, it seems that the opportunity cost issue is a dominant problem in quackery.

    Too often the argument is made that people are intrinsically stupid enough to seek out ineffective medicine. There certainly are cases but I don’t buy that as a principle; there must be a reason for alternative medicine’s success. Perhaps it’s salesmanship, flattery, marketing and superior communication.

    Unfortunately champions of rational medicine are often ineffective in communicating because they believe their patients to be too stupid to understand and act rationally. Recent movements to get patients asking more questions are poking at this problem. More that 15 seconds of meaningful doctor-patient interaction could go a long way toward tearing down normative beliefs.

  5. “But when Aunt Mary wants to treat her lung cancer with jimsonweed tea, I say: go for it. But sign off on publicly funded scientific medical care when you do; no going back. In the first place it would be ethically difficult to force a sane (?) adult to endure therapies s/he doesn’t want. In the second place there is broad instructional value to the rest of the herd when these alternative therapies fail.

    I do not mean this to sound cold or unfeeling. Every effort should be made to educate. But choices have consequences.”

    Windriven – my comment is somewhat off topic to the original article but I wanted to point out that for some people, doctor avoidance or medical intervention avoidance is tied to mental health issues. I have no idea how common this is.

    My family has a rather strong history with mental health issue, On one side this is expressed in compulsive hoarding and a sort of compulsive distrust/paranoia of authority figures (doctors, lawyers, etc.). Clearly, it’s hard to find the line between an intentional choice to seek a scam method and a choice that is based on an actual mental health disorder. It may be helpful to keep it in mind, though. If it is a mental disorder, I do think that those around the person need to make some attempt to help or get mental health help for the patient. Of course these attempts may not always be successful.

    Also, while I don’t advocate for forcing treatment on any competent adult (I don’t think anyone here does). Aunt Mary may need more emotional support, education (which you mentioned) and time to come to terms with her diagnoses. I don’t think that cutting her off from medical care in order to make an example of her is an ethical medical decision.

  6. Hubbub says:

    While it comes as little surprise to me that false hope could have the potential of being psychologically harmful, is there any data to suggest that? I’m sure a clinical trial would be difficult to get past ethics boards.

    Arm A: Given false hope
    Arm B: Died without false hope

  7. Windriven – also, not even the criminal justice system can withdraw medical care, that whole cruel and unusual punishment thing. I don’t think this argument is one of your stronger ones.

  8. windriven says:

    @micheleinmichigan

    The subject is fraught with peril and I admit to a variety of misgivings. But I did address the issues of mental health and of education.

    When a competent adult, given free access to the argument in favor of scientific medicine in the treatment of X opts instead for a sCAM treatment, a decision has been made. If after some months of “therapy” and in the face of deteriorating health the competent adult repents of his idiotic choice and shows up at the hospital for a $1,000,000 cure for what months earlier had been a $50,000 problem, what is our collective responsibility to that person?

    I am a firm believer in broadly available basic medical care for all. That care comes at a cost that I for one am perfectly happy to contribute my share to fund. With access to that care comes responsibility to use it prudently otherwise the cost to the rest of us (whether taxation or policy premiums) rises.

    Is this an ethical minefield? You bet. But if we as a people are going to support broad based health care there have to be lines or costs will spin further out of control.

  9. CarolM says:

    “Perhaps it’s salesmanship, flattery, marketing and superior communication. ”

    I notice some elderly people going in for long-term relationships with chiropractors and naturopaths in particular. It’s pretty clear that the “doctor” spends a lot of time with them, listens to them, the office overall is not that busy, so the patient gets a lot of attention without all the hustle in and out. One kept consulting even after moving hundreds of miles away.

    So I think loneliness may have something to do with it.

  10. vicki says:

    This isn’t the main issue, but it’s worth noting that “normative beliefs” aren’t necessarily correct or helpful. They are widely held, and considered important. (That the Beatles are a better band than the Monkees probably isn’t important enough to count as a normative belief.) It was once the normative belief (including in the medical profession) that homosexuality was a mental disorder. We have learned better (or at least some of us have), and in many places that belief is no longer normative.

    Conversely, germ theory was valid before it was widely known or accepted; it’s normative because it’s useful, not the other way around.

  11. windriven says:

    @CarolM

    Interesting observation. Is this a sort of borderline hypochondria do you think, where simply listening to the litany of complaints is the real therapy?

    Come to think of it, this seems more like reiki than chiropractic. The practitioner hovers her ear over the patient’s mouth and a psychic channel for defective chi is opened. ;-)

    Seriously, doesn’t this suggest a serious need for nurse practitioners or social workers who can invest the time that makes the patient feel understood?

  12. pmoran says:

    “– there must be a reason for alternative medicine’s success.”

    Here are some of them –.

    1. The power of the personal testimonial: “I used this and —-”.

    2. The mainstream, simply and truthfully, but through no fault of its own, lacks a wholly satisfactory suite of products.

    3. Public expectations of medicine are at an all-time high.

    4. Placebo and other non-specific elements of medical attentions possibly have more value than the mainstream allows from its reading of the RCTs. They at minimum ensure that any treatment at all will gain staunch followers.

    5. There is a strong compulsive element to the use of medical treatments. Doing nothing about a problem is rarely seen as an option.

  13. ConspicuousCarl says:

    Greetings to all.

    I think the emotional effects of false beliefs can just as easily be harmful as helpful.

    Anyone who spends much time on skeptical websites has probably run into some “believers” who are there to defend their favored false promise. Often, they personally have avoided established treatment for some disease.

    One form of harm they exhibit is caused by a necessary tactic of medical scams. Having no good evidence and no acceptance by authoritative sources, these false ideas survive by slandering their competition. Stories of greed and “big pharma” conspiracies are the easiest to create.

    If you follow any of these defenders of the faith, most are very angry about the big greedy conspiracy preventing “real” cures (and of course anyone would be if it were true) and are definitely not gaining mental comfort from their false belief.

    Dissenters on science websites are probably not a good representation of all quackery victims, so this might just be a minority. Maybe it is similar to religious claims, which comfort those who believe them without thinking about it too much, but generate some nasty discomfort among the few who absorb every detail of the story and let it affect their normal state of mind.

  14. chrislawrence says:

    I’m in medical school, and an argument for this I constantly hear is that conventional medicine is just as risky or has as little evidence as alternative treatments do, and if it works why not use it? I actually had a tutor tell me yesterday that “conventional medicine regards the placebo effect as something to be disregarded but alternative medicine harnesses it for true healing”. That’s from a tutor — at a supposedly evidence-based medical school.

  15. Chris says:

    I don’t know about medical school, but my experience is a tutor is usually also a student. Sometimes just a year or two ahead.

    You are well within your rights to challenge that tutor to come up with some evidence. Especially since PubMed is teaming with studies on placebos. Though my favorite is the one that got Dan Ariely the Ignobel prize, he showed that more expensive placebos work better than the cheaper ones! (it came out when I was taking a statistics class, so I used it in an assignment because it was hilarious)

  16. Dr Benway says:

    Another indirect harm: the rise of social and physical structures that depend upon public belief in nonsense –e.g., “colleges” of naturopathy, chiropractic, TCM; government agencies that “regulate” nonsense; marketing companies devoted to tarting up nonsense, pharmaceutical divisions manufacturing nonsense, departments of “integrative” medicine within academic centers, etc.

    Such structures once established endure forever.

    Think of all the poor, idealistic young people now being suckered into careers built upon nonsense when they might have helped us with the heavy lifting. Already short handed, we’re further burdened with the effort of trying to talk the anti-meds into moving out of our way.

    Novella is a brilliant guy and I love him for taking on the pseudo-scientists. But in a more perfect world he wouldn’t be so interrupted.

    tl;dr: BigNonsense becoming dangerously “too big to fail.”

  17. rwk says:

    Here’s one for Steve:
    If all this Alt. Med. stuff bothers you, how do reconcile
    walking down the halls of the hospitals you work in seeing
    chaplains,preachers,rabbis, prayer rooms and other religious
    icons?
    Offerings of communion, etc to your own patients.
    You should bring up doing away with that at the next hospital board meeting.

  18. Enkidu says:

    rwk said: “If all this Alt. Med. stuff bothers you, how do reconcile walking down the halls of the hospitals you work in seeing chaplains,preachers,rabbis, prayer rooms and other religious icons? Offerings of communion, etc to your own patients.”

    If they are not promoting prayer as a cure or alternative to conventional medicine, I don’t see a problem. I think that religious leaders are there for the comfort of the patient, like visitation from friends and family. Communion isn’t going to aleviate anyone’s pain, but it might make them feel better not to miss it on Sunday while they are laid up in the hospital.

    Ancedote: I am agnostic, but was raised Catholic and am married to a Catholic. We lost our first son at 18 weeks and had him “blessed” (baptised) after death. When my daughter was born 3 months early, the priest at the hospital baptised her a few hours after birth. It made a world of difference to me, that should something happen to her, we had that ceremony for her before her death – something we couldn’t do for our son. Did I (or my husband) think that the priest was going to magically make her lungs mature? Did the priest offer us false hope in how long she was going to need medical care? Nope and nope.

  19. DLC says:

    I always consider the worst harm from SCAMs to be that someone eschews conventional treatment for snake oil or homeopathy and so do not receive treatment. But then there is also the indirect harm done by the practitioners of SCAMs — which some call Supplements Complementary an Alternative Medicine, and I just call SCAMS — they instill this idea of being willfully ignorant, of indulging in magical thinking, that buying the snake oil is just as valid a way of operating as seeking scientifically valid treatment.

  20. “If after some months of “therapy” and in the face of deteriorating health the competent adult repents of his idiotic choice and shows up at the hospital for a $1,000,000 cure for what months earlier had been a $50,000 problem, what is our collective responsibility to that person?”

    Do you have data that suggests that late treatment of lung cancer results in more dollars rather than less?

    Really windriven? – I don’t even have the energy to go on. I saw my dad die from metastasized lung cancer and even with full effective medical care if was torture to watch, much less go through. I can’t even imagine the place you are coming from that you are thinking of these “solutions”.

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