Dr. Gorski is in the throes of grant-writing, so I’m filling in for him today by following up on a topic introduced a few months ago. It involves a key medical player in the U.S. government: Dr. Josephine Briggs, Director of the National Center for Complementary and Alternative Medicine (NCCAM).
Steve Novella and I first encountered Dr. Briggs at the 2nd Yale Research Symposium on Complementary and Integrative Medicine in March, 2010. I reported here that she seemed well-meaning and pro-science but that she also seemed naive to the political realities of her office and to much of the content of “CAM” (as illustrated by her recommending the NCCAM website, which is full of misinformation; previously I’d noticed her unfortunate innocence of “acupuncture anesthesia,” which is to be expected of most academics but not of the CAM Explicator-in-Chief).
Mea culpa to the max. I completely forgot that today is my day to post on SBM, so I’m going to have to cheat a little. Here is a link to a recent article by yours truly that appeared on Virtual Mentor, an online ethics journal published by the AMA with major input from medical students. Note that I didn’t write the initial scenario; that was provided to me for my comments. The contents for the entire issue, titled “Complementary and Alternative Therapies—Medicine’s Response,” are here. Check out some of the other contributors (I was unaware of who they would be when I agreed to write my piece).
Is it ever ethical to provide a placebo treatment? What about when that placebo is homeopathy? Last month I blogged about the frequency of placebo prescribing by physicians. I admitted my personal discomfort, stating I’d refuse to dispense any prescription that would require me to deceive the patient. The discussion continued in the comments, where opinions seemed to range from (I’m paraphrasing) “autonomy, shmatonomy, placebos works” to the more critical who likened placebo use to “treating adults like children.” Harriet Hall noted, “We should have rules but we should be willing to break them when it would be kinder to the patient, and would do no harm.” And on reflection, Harriet’s perspective was one that I could see myself accepting should I be in a situation like the one she described. It’s far easier to be dogmatic when you don’t have a patient standing in front of you. But the comments led me to consider possible situations where a placebo might actually be the most desirable treatment option. If I find some, should I be as dogmatic about homeopathy as I am about other placebos?
Nicely, Kevin Smith, writing in the journal Bioethics, examines the ethics of placebos, based on an analysis of homeopathy. Homeopathy is the ultimate placebo in routine use — most remedies contain only sugar and water, lacking a single molecule of any potentially medicinal ingredient. Smith’s paper, Against Homeopathy — A Utilitarian Perspective, is sadly behind a paywall. So I’ll try to summarize his analysis, and add my perspective as a health care worker who regularly encounters homeopathy.
A good case of smallpox may rid the system of more scrofulous, tubercular, syphilitic and other poisons than could otherwise be eliminated in a lifetime. Therefore, smallpox is certainly to be preferred to vaccination. The one means elimination of chronic disease, the other the making of it.
Naturopaths do not believe in artificial immunization . . .
—Harry Riley Spitler, Basic Naturopathy: a textbook (American Naturopathic Association, Inc., 1948). Quoted here.
Here’s what a good case of smallpox will do for you:
If you’re lucky enough to beat the reaper (20-60%; 80% or higher in infants) or blindness (up to 30%), those blisters will leave you scarred for life. Oh, and the next time a good smallpox epidemic comes around, your children born since the last one will catch it and contribute their fair share to the death rate. But not you because you’ll be immune, so you’ll have the “preferred” experience of watching your children die well before you do.
UPDATE 4/27/2011: Here’s the online video of Dr. Novella’s appearance on The Dr. Oz Show:
- Controversial Medicine: Alternative Health, Part 1
- Controversial Medicine: Alternative Health, Part 2
- Controversial Medicine: Alternative Health, Part 3
I must say I was a bit shocked two weeks ago when I was contacted by a producer for The Dr. Oz Show inviting me on to discuss alternative medicine. We have been quite critical of Dr. Mehmet Oz over his promotion of dubious medical treatments and practitioners, and I wondered if they were aware of the extent of our criticism (they were, it turns out).
Despite the many cautions I received from friends and colleagues (along with support as well) – I am always willing to engage those with whom I disagree. I knew it was a risk going into a forum completely controlled by someone who does not appear to look kindly upon my point of view, but a risk worth taking. I could only hope I was given the opportunity to make my case (and that it would survive the editing process).
Of course, everyone was extremely friendly throughout the entire process, including Dr. Oz himself (of that I never had any doubt). The taping itself went reasonably well. I was given what seemed a good opportunity to make my points. However, Dr. Oz did reserve for himself the privilege of getting in the last word—including a rather long finale, to which I had no opportunity to respond. Fine—it’s his show, and I knew what I was getting into. It would have been classy for him to give an adversarial guest the last word, or at least an opportunity to respond, but I can’t say I expected it.
Take up the White Man’s burden–
The savage wars of peace–
Fill full the mouth of Famine
And bid the sickness cease;
And when your goal is nearest
The end for others sought,
Watch CAM and woo Folly
Bring all your hopes to nought.
The White Man’s burden, a bit of racism from the 19th century:
The term “the white man’s burden” has been interpreted as racist, or taken as a metaphor for a condescending view of non-Western national culture and economic traditions, identified as a sense of European ascendancy which has been called “cultural imperialism.” An alternative interpretation is the philanthropic view, common in Kipling’s formative years, that the rich have a moral duty and obligation to help “the poor” “better” themselves whether the poor want the help or not. The term “the white man’s burden” has been interpreted as racist, or taken as a metaphor for a condescending view of non-Western national culture and economic traditions, identified as a sense of European ascendancy which has been called “cultural imperialism.” An alternative interpretation is the philanthropic view, common in Kipling’s formative years, that the rich have a moral duty and obligation to help “the poor” “better” themselves whether the poor want the help or not.
I will let the commentators debate the meaning of the poem. There are places in the world so devastated by poverty, disease and political corruption that it may be beyond the capacity of the local populations to overcome. They need outside help. Certainly, the impulse to help those less fortunate than yourselves is a noble tradition. Haiti, Central America and Uganda are parts of the world that need assistance in overcoming an incredible number of problems to reach even a basic level of material support for its population.
I’ve frequently lamented what might happen if the current trend towards quackademic medicine continues unabated, and quackery becomes fully “integrated” with science-based medicine as a co-equal. Interestingly, this concept has provided fodder for several comedians. For example, the first comedy sketch I discovered on this theme was homeopathic e.r. Then a couple of years ago, Mitchell and Webb brought us the British version of essentially the same idea (but done so much better), namely Homeopathic A&E. What I didn’t realize is that predating both of these was…Holistic E.R. (Embedding disabled, unfortunately.)
This sketch comes from an old sketch comedy show known as Almost Live!, which I had never heard of before, but if this sketch is any indication, it was brilliant. Favorite bits from Holistic E.R.: The part about vitamin C, the use of visualization, and, of course, the crystals. Sadly, with the way academic medicine is being infused with quackery such as energy healing, homeopathy, and even anthroposophic medicine at my medical alma mater, I could see this happening within my lifetime.
I do a lot of driving as part of my job. I am the sole Infectious Disease doctor at three hospitals and I can spend an hour or two a day in the car, depending on traffic. What prevents me from going crazy sitting in traffic is listening to podcasts and audible books. I especially like reading (and yes, audio books is reading, pedant) multivolume epics. Currently I am reading Steven King’s Dark Tower series, which occurs in a universe “where the world has moved on.” In Mid-world there was once a world with science and beauty and art, but something changed, what I do not know yet (I am only on the third volume; no spoilers in the comments), and the world moved on, leaving behind some artifacts of science and technology, but it appears to be an increasingly primitive world. Being fantasy, there is, unlike the world I live in, magic as well.
I like that phrase: “the world has moved on.” (more…)
Science is a philosophy, a technology, and an institution. It is a human endeavor- our collective attempt to understand the world around us, not something that exists solely in the abstract. All of these aspects of science have be progressing over the past decades and centuries, as we refine our concepts of what science is and how it works, as we develop better techniques, and organize and police scientific activities more effectively. The practice of science is not relentlessly progressive, however, and there are many regressive forces causing pockets of backsliding, and even aggressive campaigns against scientific progress.
So-called complementary and alternative medicine (CAM) is one such regressive force. It seeks to undermine the concepts, execution, and institutions of medical science in order to promote sectarian practices and ideological beliefs. Examples of this are legion, exposed within the pages of this blog alone. I would like to add another example to the pile – the recent defense of homeopathy by Dana Ullman in the Huffington Post (names which are already infamous among supporters of SBM).
In a piece titled: Homeopathy for Radiation Poisoning, Ullman demonstrates yet again the pseudoscientific aspects of homeopathy and its proponents. The primary principle that is abused by Ullman this time is the need for scientists to carefully define their terms and concepts. Scientific concepts should be defined as carefully, precisely, and consistently as possible. Squishy concepts are very difficult to deal with in science – but are the bread and butter of pseudoscience.
Steven Salzberg, a friend of this blog and Director of the Center for Bioinformatics and Computational Biology at the University of Maryland, is on the editorial boards of three of the many journals published by BioMed Central (BMC), an important source of open-access, peer-reviewed biomedical reports. He is disturbed by the presence of two other journals under the BMC umbrella: Chinese Medicine and BMC Complementary and Alternative Medicine. A couple of days ago, on his Forbes science blog, Dr. Salzberg explained why. Here are some excerpts:
The Chinese Medicine journal promotes, according to its own mission statement, studies of “acupuncture, Tui-na, Qi-qong, Tai Chi Quan, energy research,” and other nonsense. Tui na, for example, supposedly “affects the flow of energy by holding and pressing the body at acupressure points.”
Right. What is this doing in a scientific journal?… I support BMC…But their corporate leaders seem to care more about expanding their stable than about maintaining the integrity of science. Chinese Medicine simply does not belong in the company of respectable scientific journals.
Forming a scientific journal whose goal is to validate antiquated, unproven superstitions is simply not science, whatever the editors of Chinese Medicine claim.
BMC should be embarrassed to be publishing journals that promote anti-scientific theories and otherwise muddy the literature. By supporting these journals, they undermine the credibility of many excellent BMC journals. They should cut these journals loose.