Medical Ethics

Archive for Medical Ethics

Parabiosis – The Next Snakeoil

parabiosisThe pattern has repeated so many times that it is truly predictable. Scientists turn their eyes to one type of treatment that has theoretical potential. However, proper research from theory to proven treatment can take 10-20 years, if all goes well. Most such treatments will not work out – they will fail somewhere along the way from the petri dish to the clinic.

However, the media likes a good story, and one of their favorite narratives is the “new miracle cure.” They will often take preliminary basic science research and present it with headlines promising a cure for some horrible disease (sometimes they will add a question mark).

When we see these headlines, we know what will happen next – hucksters will ride the hype with a wave of snake oil products promising the same cure, and claiming to be based in science. Dr. Oz will probably promote it on his show, and Mike Adams will rant about the government conspiracy to keep this cure from the public (but he will sell it to you).

We have seen this pattern with antioxidants, stem cells, resveratrol, and countless others. Sometimes the hucksters manufacture their own hype, as with green coffee beans. They don’t wait for actual scientists, they corner the market on some worthless bean or berry, then invent health claims for it and try to hype demand through the usual channels. This sadly works. (more…)

Posted in: Medical devices, Medical Ethics

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Forget stem cell tourism: Stem cell clinics in the US are plentiful

Snake Oil Salesman & Wagon
I had planned on writing about something else this week, but late last week another story caught my eye, because it served as a perfect follow-up to what I wrote about last week. To recap, I wrote about a man named Jim Gass, a former chief legal counsel for Sylvania, who had suffered a debilitating stroke in 2009 that left him without the use of his left arm, and weak left leg. He could still walk with a cane, but was understandably desperate to try anything to be able to function more normally in life. Mr. Gass was both driven enough, credulous enough, and wealthy enough to spend $300,000 pursuing stem cell tourism in China, Mexico, and Argentina over the course of four years. The result is that he now has a tumor growing in his spinal column, as reported in The New England Journal of Medicine (NEJM) and The New York Times (NYT). Genetic analysis has demonstrated that the cells in this tumor mass did not come from Jim Gass, and the mass has left him paralyzed from the neck down, except for his right arm, incontinent, and with severe chronic back pain. Worse, although radiation temporarily stopped the tumor from growing, apparently it’s growing again, and no one seems to know how to stop it. Given that the traits that make stem cells so desirable as a regenerative treatment, their plasticity and immortality (ability to divide indefinitely), are shared with cancer, scientists doing legitimate stem cell research have always tried to take precautions to stop just this sort of thing from happening in clinical trials. Clearly, “stem cell tourist” clinics, which intentionally operate in countries where the regulatory environment is—shall we say?—less than rigorous are nowhere near as cautious, as they charge tens of thousands of dollars a pop for stem cell treatments that might or might not actually have real stem cells in them.

At the time I wrote that article, I emphasized primarily clinics outside of the US, where shady operators locate in order to be able to operate largely unhindered by local governments. You’d think that such a thing couldn’t possibly be going on in the US. You’d be wrong. Last week, Paul Knoepfler, a stem cell scientist who has previously contributed to Science-Based Medicine, teamed up with Leigh Turner to publish a paper in Cell Stem Cell estimating the number of stem cell clinics in the US. The number they came up with astonished me. (more…)

Posted in: Clinical Trials, Medical Ethics, Politics and Regulation, Science and the Media

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Academic Consortium plan: force medical residents to practice integrative medicine

The Integrative Medicine Wheel

The Integrative Medicine Wheel

“Integrative medicine” (IM) is an ideological movement within medicine driven in large part by those whose livelihoods depend on its continued existence. This includes both those with positions in academic medicine and individual practitioners who use the IM brand to attract patients.

Despite IM and its antecedents (alternative, complementary, alternative and complementary, complementary and integrative) having been around for about a quarter century, we still do not have a working definition of integrative medicine or have any idea whether it positively affects patient outcomes. And, despite the lip service given to IM being evidence-based, or “evidence-informed” or incorporating “appropriate” services into conventional medicine, there does not seem to be any standard for determining which modalities are appropriate for inclusion. We can infer, however, that evidence of effectiveness is not a criterion, as reiki, cranial sacral “therapy”, and homeopathy are standard fare.

In fact, the prospect for actually improving patient outcomes by importing CAM treatments (such as acupuncture) into medical practice would seem to be decreasing over time, as more and more fail to hold up under the scrutiny of well-designed and conducted clinical trials. Perhaps the dearth of evidence for “alternative” treatments is the impetus behind the importation of conventional modalities, such as nutrition and exercise, into the IM fold, treatments that were never viewed as CAM when the whole enterprise started. It has also led to special pleading demanding that research standards be loosened, most recently by the NCCIH, its director’s promise to ensure “rigorous science” notwithstanding.

There is no standard delivery model for integrative medicine or, importantly, an agreed-upon role for the various practitioners who bring the “integrative” to integrative medicine, such as chiropractors, naturopaths and acupuncturists. For example, should they be allowed to practice independently or should the medical doctor have final say on patient care? And, if they differ in their proposed diagnoses and treatments, how are those issues to be resolved? (more…)

Posted in: Acupuncture, Chiropractic, Ethics, Medical Academia, Medical Ethics, Naturopathy

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Is it ethical to sell complementary and alternative medicine?

Legal to sell, yes. But ethical to sell?

Legal to sell, yes. But ethical to sell?

Complementary and alternative medicine (CAM) is no longer fringe, and anything but the mom-and-pop image that manufacturers carefully craft. CAM is big business, and most Americans today take some sort of supplement. The impetus for my blogging (and tilting at CAM windmills) emerged from years spent working in a pharmacy with a heavy reliance on CAM sales. If it was unorthodox, this store probably sold it. Conventional drug products (the ones I was familiar with) were hidden off in a corner, and the store was otherwise crowded with herbal remedies, homeopathy, and different forms of detox kits and candida cleanses. All of this was unlike anything I’d ever seen or heard about in pharmacy school – so I started researching.

I looked at CAM from a scientific evidence perspective, the one I was taught in pharmacy school, using the same approach I’d take when assessing a new drug. Did the evidence support the claims made about these products, or not? The answers, as you might expect, were often the same. There was little or no credible evidence to demonstrate CAM had any meaningful benefits. I started blogging my own reviews as a way of documenting my own research, while offering some information to anyone on the Interwebs who might be searching for evidence.

Over time my blogging focus expanded, as I asked myself the inevitable questions: How could implausible products with no scientific backing even be approved for sale at all? I discovered the regulatory double-standard allowed for anything considered a dietary supplement (or in Canada, a “natural health product“) and the history and politics that have made CAM the “Wild West” of health care, with a marketplace that prioritizes a manufacturer’s right to sell over a consumer’s right to purchase a product that is safe and effective. Given the retail marketplace that’s been established by regulators like the FDA and Health Canada, I’ve turned my focus on to health professionals, who have an ethical responsibility to put patient interests above that of commercial interests. From a professional practice and medical ethics perspective, I have argued that health professionals that sell or promote CAM are on ethically shaky ground, and compromise the credibility of the profession.

Despite the lack of evidence that CAM (in general) offers any health benefits at all, it’s been remarkable to watch its popularity grow, to the point where even large pharmacy chains now sell aisles of products that are implausible and often highly questionable. Generally meeting these changes with a collective shrug, the pharmacy profession has even tried to lower its own ethical standards. While I do get the occasional encouragement from some of my peers, most just say “it’s business” or “the customer wants it, and these are legal products.” My argument today is CAM fails even this lower ethical bar. (more…)

Posted in: Ethics, Herbs & Supplements, Homeopathy, Medical Ethics, Politics and Regulation

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The fine line between quality improvement and medical research


As I’ve mentioned before, the single biggest difference between science-based medicine (SBM) and what I like to call pseudoscience-based medicine, namely the vast majority of what passes for “complementary and alternative medicine” (CAM) or “integrative medicine” is that SBM makes an active effort to improve. It seeks to improve efficacy of care by doing basic and clinical research. Then it seeks to improve the quality of care by applying the results of that research to patient care. Yes, the process is complicated and messy, and it frequently doesn’t progress as fast as we would like it to. Sometimes it goes down blind alleys or takes wrong turns, such as when a treatment is adopted too rapidly and determined later to be ineffective. Overall, however, improvement does occur, and it continues to occur. New treatments that work better are discovered. Old treatments that don’t work as well (or that don’t work at all) are abandoned.

There is, however a blurry line between what constitutes medical research and what constitutes quality improvement (QI). A couple of years ago, in one of those unexpected turns that a career can take, an opportunity presented itself for me to become co-director of a statewide quality improvement consortium for breast cancer care in my state. As I’ve alluded to before, it was a case of unexpectedly being in the right place at the right time, of seeing an opportunity and being willing to take it. How I ended up making quality improvement a large part of my career is unimportant. What is important is that it puts me in a unique position among all the other SBM contributors to discuss the interface between science and quality. (It’s also important that I lay down a disclaimer here that this post represents my opinion and my opinion alone; it does not represent the views of the QI with which I’m affiliated, my cancer center, or my university.) In particular, there are ethical considerations that are not obvious, apparently even to someone as brilliant as Steven Pinker, who Tweeted yesterday:

Posted in: Clinical Trials, Medical Ethics, Quality Improvement

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Worshiping at the altar of the Cult of the Brave Maverick Doctor

Death of Cancer

One of my favorite television shows right now is The Knick, as I described before in a post about medical history. To give you an idea of how much I’m into The Knick, I’ll tell you that I signed up for Cinemax for three months just for that one show. (After its second season finale airs next Friday, I’ll drop Cinemax until next fall.) The reason why I’m bringing up The Knick (besides I love the show and need to bring it up at least once a year) is because an article by Malcolm Gladwell in The New Yorker entitled “Tough Medicine“, which is a commentary based on a new book on cancer by a veritable god of cancer research, Vincent T. DeVita, Jr., immediately resonated with a storyline in this season of The Knick. I haven’t yet read The Death of Cancer: After Fifty Years on the Front Lines of Medicine, a Pioneering Oncologist Reveals Why the War on Cancer Is Winnable–and How We Can Get There by Vincent T. DeVita and Elizabeth DeVita-Raeburn, but I want to. I can tell, though, that there will be parts of the book I find annoying just from Gladwell’s take on it, which approvingly describes DeVita as railing against the cautiousness and incremental nature of today’s cancer research. To give you an idea of where Gladwell’s coming from, I note that his article shows up in the title bar of my web browser not as “Tough Medicine” but rather “How To Cure Cancer”, even as the title on the web page itself remains “Tough Medicine”. On the other hand, the article does conclude with Gladwell demonstrating a better understanding of the disadvantages of what DeVita is proposing than it seems that he will in the beginning. In fact, it is Gladwell who is more reasonable than his subject, although he does appear share DeVita’s apparent assumption that potentially all cancer patients are savable if only we try hard enough. (more…)

Posted in: Cancer, Clinical Trials, History, Medical Ethics

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The Ethics of Prescribing Worthless Treatments

ethics smallIs 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.


Posted in: Health Fraud, Medical Ethics

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To debate or not to debate: The strange bedfellows of Andrew Weil

Andrew Weil

To debate or not to debate, that is the question.
Whether it is nobler in the mind to suffer
The slings and arrows of outrageous quackery
Or to take arms against a sea of quackademia,
And, by opposing end them.

Hamlet, Act III, Scene 1, paraphrased badly.


The question of whether it is worthwhile to debate cranks, quacks, and advocates of pseudoscience has long been a contentious issue in the skeptic community. Those of you who’ve been reading my posts for a while know that I’ve always come down on the side that it is not a good idea One thing I’ve learned in my more than a decade of blogging, both here and at my not-so-super-secret other blog, is that advocates of pseudoscience love public debates. Indeed, whenever you see a skeptic agree to a public debate with an advocate of pseudoscience, it’s a damned sure bet that it wasn’t the skeptic who proposed it. I suppose it’s possible that there have been such instances that I’m unaware of, but I do know of a lot of instances where it was the other way around. I’ve even witnessed one myself, when our fearless founder Steve Novella debated antivaccine quack Julian Whitaker about vaccine safety at FreedomFest in Las Vegas while we were at TAM three years ago. Steve mopped the floor with Dr. Whitaker so dramatically that it almost changed my mind about the value of debates with quacks because, witnessing the debate, I saw that the arguments Dr. Whitaker marshaled were such hackneyed antivaccine talking points that I knew I could also have demolished them. Still, in the end, no minds were likely to be changed, and the question of vaccine safety was clearly being used as a tool to oppose school vaccine mandates or, as antivaccinationists like to call them deceptively, “forced vaccination.” Whether vaccines are safe and effective or not is a separate question from whether the government should mandate certain vaccines as a precondition for attending school or being in day care.

Over the years, I myself have been “challenged” to similar debates myself. Perhaps the most bizarre example occurred when someone claiming to represent HIV/AIDS denialist Christine Maggiore contacted me claiming that she wanted to arrange a debate between us. Maggiore, unfortunately, died a mere two years later of—you guessed it—AIDS-related complications. Although occasionally the ego gratification of being asked to participate in such events vied with my longstanding belief that debating cranks doesn’t sway anyone, sharing the stage with a real scientist does unduly elevate the crank in the eyes of the public. Besides, whatever the seeming outcome of the debate, you can count on the crank to declare victory and his believers to agree. In any event, science isn’t decided by the metrics used to judge who “wins” a public debate, which rely more on rhetoric and cleverness rather than science to decide the outcome. Finally, such debates are not without risks. Although Julian Whitaker, for example, was terrible at it, other cranks are adept at the Gish Gallop, and an unprepared skeptic or scientist can be made to appear clueless in front of a crowd that is almost always packed with supporters of the crank, not the skeptic.

Just last week, there was another “debate” challenge that led me to question my resolve not to debate cranks. It came from a most unexpected source.

Posted in: Medical Academia, Medical Ethics, Science and the Media

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Learning quackery for Continuing Medical Education credit



The Integrative Addiction Conference 2015 (“A New Era in Natural Treatment”) starts tomorrow in Myrtle Beach, SC. Medical doctors, doctors of osteopathy, naturopaths and other health care providers will hear lectures on such subjects as “IV Therapies and Addiction Solutions,” given by Kenneth Proefrock, a naturopath whose Arizona Stem Cell Center specializes in autologous stem cell transplants derived from adipose tissue. Proefrock, who was disciplined for using prolotherapy in the cervical spine without proper credentialing in 2008, claims that stem cells treatments are an “incredibly versatile therapy” and uses them for variety of conditions, such as MS and viral diseases. At the same time, he admits that they are not FDA approved and he is not claiming they are effective for anything (and he’s right), which leads one to wonder why he employs them.

Proefrock also offers a typical naturopathic mish-mash of services, from oncology to urology to “naturopathic endocrinology,” and claims he specializes in treating influenza, high blood pressure and kidney stones, as well as addiction. In other words, he doesn’t seem to be the sort of expert you’d find speaking at a science-based conference on addiction medicine.

You’ll find similarly troubling bios of some of the other speakers, as well as dubious treatments for addiction, on the conference website. Here, for example, are speaker Giordano’s and Eidelman’s websites.

Dalal Akoury, MD, is the “Title Sponsor” of the conference and appears to be running the show. Although she is listed by the S.C. Board of Medicine as board certified in pediatrics, she is the founder of the “Integrative Addiction Institute” and runs the “AwareMed Health and Wellness Resource Center” in Myrtle Beach. Like the Arizona Stem Cell Center, it offers a range of treatments that defy categorization as any particular specialty: addiction recovery, “adrenal fatigue” treatment, stem cells, “anti-aging,” weight loss, “functional medicine” and “integrative cancer care“. Yet, only Akoury and one licensed practical nurse are on the staff of the Center. Again, it is questionable whether she is has sufficient qualifications in addiction medicine to run a conference on the subject. (more…)

Posted in: Acupuncture, Cancer, Chiropractic, Dentistry, Diagnostic tests & procedures, Energy Medicine, Homeopathy, Medical Academia, Medical Ethics, Naturopathy

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Is Homeopathy Unethical?

Homeopathy is full of crap!  Click to embiggen.

Homeopathy is full of crap! Click to embiggen.
Borrowed with loving attribution from Hell’s News Stand. Go to He…go there!

“A gentle ethical defence of homeopathy” by Levy et al. was recently published in an ethics journal. A full-text preprint is available online. They say:

Utilitarian critiques of homeopathy that are founded on unsophisticated notions of evidence, that adopt narrow perspectives on healthcare assessment, and that overstate the personal, social and ontological harms of homeopathy, add little to our understanding of the epistemology of medicine. But when they are used to denounce the ethics of homeopathy – they are not only ill-considered and counterproductive, but philosophically and socially perverse.

I found their arguments unconvincing. (more…)

Posted in: Homeopathy, Medical Ethics

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