Is it ever ethical for a physician to prescribe a treatment to a patient that they know to be entirely without efficacy? Is it ever possible to do this without deceiving the patient to some degree? I think the answer to both questions is a clear “no.”
Within the flipped reality of “alternative medicine,” however, it suddenly becomes acceptable to deceive patients and sell them worthless treatments, as long as the deception was minimally successful.
A recent editorial in Scientific American by Allison Bond addresses this question. She manages to hit upon many of the reasons placebo medicine is inappropriate, but her reasoning is a bit muddled and she comes, in my opinion, to the wrong conclusion. She wraps her commentary in an anecdote of a terminal patient for whom she cared who found relief from reiki. She concludes:
Of course, when it comes to treating patients with painful, life-threatening diseases, the goal of our care should be to lessen suffering, regardless of where such relief originates. A few months after Ms. W left the hospital, I learned that she had died, and the news hit me hard. I thought back to her treatment under our care and hoped that even among the misery, we had eased her suffering through our therapies—“alternative” or not.
If you have not heard of CRISPR yet, you should have. This is a truly transformative technology that allows for cheap and easy gene editing. It makes a powerful technology easily accessible.
Powerful biological technology, like stem cells to give another example, always seem to provoke profound hope and fear. The ability to manipulate human biology comes with it the hope of treating horrible and currently untreatable diseases. At the same time such technology provokes fear that it will be abused, or that it will violate the sanctity of what it means to be human.
As the public debate over stem cells seems to be fading into the background a bit (like IVF before it), debates over CRISPR and gene editing are likely to come to the forefront.
What is CRISPR?
There is no escaping the evidence that regular moderate exercise is associated with a host of medical benefits. Among those benefits are perhaps improved memory and cognition, and questionably a decreased risk of developing dementia.
The latest study to show this correlation involved younger and older adults who wore a step-monitor. The number of steps they took during the study interval was then correlated with their performance on neuropsychological testing. The researchers found that for the older adults, but not younger adults, more physical activity correlated with better overall cognitive performance, but especially for face-name recognition.
This is a small study, with 60 subjects total. Also, the study is correlational only. It is possible that healthier older adults are both more physically active and cognitively nimble, because of underlying biological fitness. More cognitively active older adults may also be more physically active – the lines of cause and effect are plausible in multiple ways. (more…)
The Robert F. Kennedy building in Washington, DC, headquarters of the United States Department of Justice
It is shaping up to be a good year for those of us advocating more effective regulation of supplements and unproven therapies in the US. The Food and Drug Administration (FDA) is reviewing its regulation of homeopathy, and recently also announced it is taking public comment on its regulation of the term “natural.” The Federal Trade Commission (FTC) is also reviewing the claims made by the homeopathy industry, and even gave a nudge to the FDA to fix its regulation.
Now the US Department of Justice (DOJ) is getting in on the fun:
USPlabs, which sold the best-selling workout supplement Jack3d, and six of its executives face criminal charges for the unlawful sale of nutritional supplements, the U.S. Justice Department said Tuesday in announcing a larger probe by federal agencies aimed at stemming the sale of unproven products.
This action by the DOJ raises the stakes to a new level – criminal charges. While the FDA and FTC do the best they can, they often lack teeth when it comes to supplements. The FDA might issue a polite request and then escalate to a stern warning when companies step out of line. The FTC can issue fines which amount to little more than a slap on the wrist – the cost of doing business. Both agencies are playing whack-a-mole and losing.
Increasingly people are accessing healthcare information in order to make decisions for their own health. A 2010 Pew poll found that 80% of internet users will do so for health care information. This presents a huge potential benefit, but also a significant risk.
Daniel Levitin talks about the need for public information literacy, something we also discuss frequently here on SBM. If you are accessing the internet to inform your health care decisions, then you need to know how to determine the legitimacy and trustworthiness of the websites you are visiting. There is a big difference between NaturalNews (a crank site full of misinformation and conspiracy theories) and Nature News (an outlet for one of the most prestigious science journals in the world).
Even when you can discriminate between good and bad health information websites, the challenge remains to properly interpret the scientific information to which you now have access.
Last week a Hawaiian woman living in Las Vegas, Chelsea Ake, was found dead in a cryotherapy chamber where she works. Apparently she was using the chamber unsupervised and accidentally locked herself in or passed out, and was found 10 hours later. Her death, of course, is tragic and we have nothing but sympathy for her and her family.
The event, however, was the first time many people heard of whole body cryotherapy (WBC) and prompted many questions. Three months ago Zachary Hoffman published a guest post on SBM about cryotherapy, showing that the science is just not there. He focused mainly on using ice packs to treat sprains and sports injuries (which is surprisingly not evidence-based, but also perhaps not unreasonable), I am going to focus on using WBC for general health.
What is whole body cryotherapy?
As is often the case, perfectly legitimate or perhaps preliminary medical procedures are hijacked by entrepreneurs and hyped into a bogus “spa” therapy, snake oil, or medical device. Preliminary evidence or legitimate uses are then used to justify the pseudoscientific extrapolations. Stem cells are a legitimate area of medical research, but I would not go to a stem cell clinic in China to treat your ALS.
A new study looked at clinical trials for neuropathic pain over the last 23 years and found that the response of subjects in the placebo group has been increasing over time, but only in the United States. The cause of this increase is unknown, and has provoked a fascinating discussion about the nature of placebos and their role in medical research.
What is the placebo effect?
We have discussed the placebo response at length here at SBM because the concept is critical to understanding clinical science, and it is largely misunderstood. Most often it is presented as a mind-over-matter response to the expectation of benefit. Proponents of worthless treatments often hype the placebo response as if it can have real healing power, when the evidence shows it does not.
In reality, there are a large number of placebo effects and the phenomenon is quite complex. In clinical trials “the placebo effect” is whatever happens in the placebo group of the study, the group receiving an inactive treatment. This is not one effect, however, but a complex combination of many effects.
When skeptics hear the term “vibration” a red flag goes up, because that is a common term used in pseudoscientific jargon. Vibrations are often used to refer vaguely to energy or some physical or even spiritual property that cannot be detected, and is used in a hand-waving manner to explain extraordinary claims.
Vibrations, however, are also a real thing, referring to physical oscillations. Whole body vibration therapy (WBVT) refers to these legitimate physical vibrations. It is being offered as a treatment for balance, back pain, neurological disorders, and also simple fitness. Does it actually work, however, for the indications claimed?
What is WBVT?
WBVT is considered a passive exercise modality, in which something is being done to the person, rather than the person actively engaging in an activity, such as walking, weight lifting, or swimming. With WBVT users lay, sit, or stand on a platform that vibrates rapidly in one or more directions. The idea is that the rapid vibrations force the muscles of the body to contract in reaction, providing a form of exercise.
The overall goal of science-based medicine is to maintain and improve the standard of science in the practice of medicine at every level. At the heart of the scientific basis of medical knowledge and practice is a process known as peer-review. We have occasionally written about peer-review on SBM, and once again the process is under the microscope over a specific question – should peer review be open or blinded?
What is peer review
The term peer-review refers to a pre-publication process in which a journal editor will send a submitted manuscript to 2-3 experts in a field relevant to the paper to carefully examine every aspect of the paper. They then provide a detailed analysis of the paper: is the research question relevant and appropriate, did the study design properly address the question, were the methods rigorous, was the statistical analysis appropriate, was the data presented fairly, are the conclusions supported by the data, did the authors account for other publications addressing the same issue, and did they address every possible question or objection?
The reviewers’ reports will make specific recommendations for changes that would be necessary to improve the paper, and also make their bottom-line recommendation: accept as is, accept with revisions, or deny. The journal editor(s) then rely upon those reviews, plus their own assessment, to make a final decision.