Guest Book Review of “Complementary and Alternative Medicine: Ethics, the Patient, and the Physician”
The following book review was written not by your poster (although I’ve added the hyperlinks), but by his friend Cees Renckens, who is a gynecologist in the Netherlands and the chairman of the Dutch Society against Quackery. A short bio of Dr. Renckens, including references to several articles in English, follows the review. Most impressive to me is that he is, as far as I know, the first and only person in the world to have earned a PhD in a field that describes much of the content here at Science-Based Medicine: the rational evaluation of anomalous and implausible medical practices.
For several years, Dr. Renckens and the Dutch Society have been embroiled in a disturbing legal case involving freedom of speech. This was previously mentioned on SBM by astute reader Dr. Peter Moran. According to Dr. Renckens, the Dutch Supreme Court will issue its final judgment of the case at the end of February.
Complementary and Alternative Medicine: Ethics, the Patient, and the Physician. Edited by Lois Snyder, 241 pp, $69.50, Totowa NJ, Humana Press (2007). ISBN 58829-584-2.
Reviewed by Cees N. M. Renckens, MD, PhD
During the second half of the 20th century, the Moerman anti-cancer diet was very popular in the Netherlands. Moerman was a family physician with no training in oncology or nutrition. He kept carrier pigeons and believed that his birds never got cancer. Therefore he developed a diet based on food for carrier pigeons. He had no contact with oncologists, nutritionists or other physicians. The Inspector for Public Health for his area was of the opinion that Moerman had “serious medical-ethic defects.”
Add to this example the fact that “alternative” physicians appear to be successful in presenting their approach as highly ethical, with its respect for old wisdom, for the ideas and peculiarities of their patients, and for treatments borrowed from Ayurvedic, Chinese, Tibetan and other third world medical systems, all of which can be classified as backwards, and you can understand why my interest was immediately aroused when I learned that a book had been issued with the title Complementary and Alternative Medicine. Ethics, the Patient and the Physician.
Finally, I thought, a look through ethical glasses at the deceit, at the admissibility of shoddy scientific research of “alternative” treatments, and perhaps a discussion of the necessary rigor of academic medicine and about how to deal with those who reject such rigor. When, in a short review in the Mayo Clinic Proceedings, the book was judged to be “excellent,” I dispelled my dislike of the rather high price and ordered it.
The contents, however, were bitterly disappointing. Editor Lois Snyder, a lawyer and ethicist working for the American College of Physicians, who had edited earlier books about stem cell research, cloning, reproductive technology, AIDS, care for the elderly, assisted suicide, and more, has produced with this book a messily edited and one-sided piece of work. This could possibly have been inferred from the title, because in 1998 its predecessor in the same series (Biomedical Ethics Reviews) was called Alternative Medicine and Ethics. The authors are clearly infected by the undeserved euphemism “complementary,” with which the present-day quack likes to adorn himself. (That I continue to adopt the abbreviation CAM in this piece is for practical reasons and does not imply any agreement with this usage).
The book consists of seven chapters written by the same number of authors, whose minds, according to their short CVs, are richly endowed by alternative ideas. Michael Cohen is a lawyer connected with the Harvard Medical School Osher Institute and Division for Research and Education in Complementary and Alternative Therapies. Arti Prasad is physician and founding chief of the “Center for Life Integrative Medicine Clinic” at the University of New Mexico, and “has a lifetime of experience with natural and ayurvedic medicine.” She “completed an associate fellowship at the Program in Integrative Medicine at the U. of Arizona…under the direction of Dr. Andrew Weil.”
After Lois Snyder has listed her own CV twice—on the other hand Wayne Vaught’s is missing completely—we read on John Tilburt’s CV that this MD was a student at the Johns Hopkins Complementary and Alternative Medicine Center and that since 2005 he has been employed by the Department of Clinical Bio-Ethics of the NIH. With the support of the NCCAM he has been applying himself to the “social and ethical aspects of CAM.” Finally, Mariebeth Velasquez is a student of medicine in the University of New Mexico, who became interested in CAM “while participating on a research team at the Fred Hutchinson Cancer Research Center.” Only two contributors, attorney Catherine Leffler (Snyder’s colleague at the ACP) and cardiologist Richard J. Carroll, lack obvious predilections for “CAM.”
After an introduction by Snyder, subsequent chapters discuss the purported necessity of this book (the enormous consumption of CAM in the USA), the definitions, the users, the duties of the physicians with respect to CAM, how to advise patients, the education of physicians and patients with respect to this subject, legal aspects and risks, and finally the ethical aspects of CAM research. The best that can be said is that the chapters provide extensive lists of references to all kinds of (English language) literature about CAM.
Unfortunately, sympathy for such treatments and ‘respect’ for the autonomy of the (deceived) citizens who desire them jumps from every page. For instance, statistics are quoted that supposedly show that 110 million people (36% of the population of the USA) use CAM, but these numbers—repeatedly criticized by people like Sampson, Barrett and Renner—include such methods as praying, massage and swallowing vitamin pills.
When, in the chapter about the ethical duties of the physician, the author (Vaught, p. 60) talks about the “infamous website of Barrett,” your reviewer had trouble continuing to read. After all, Barrett’s Quackwatch website is of a unique quality and is very reliable. Four pages earlier the same author had asserted that each physician ought to be well informed about CAM because otherwise he/she might deprive the patient of “important health benefits.” And how often, writes Vaught, has not regular medicine introduced new methods without good research? A truism, but not really an excuse to do the same!
It was with particular interest that I read the last chapter, by Tilburt, about the “Ethical Challenges in CAM Research.” How ethical can it be to expose patients to research for which there is, beforehand, no serious doubt about the result? The “equipoise” is missing in this sort of research, and even a positive result will not lead to an adjustment of the current biomedical model (which, on p. 39 of this book, is described as ‘the cultural, politically dominant system of the time defining the scientific model as a paradigm’). The author does notice the problem and calls for “medical pluralism,” which boils down to a “commitment to openness”: one should not be too quick to reach the qualification “quackery” on the basis of biological implausibility. This requires respect and a dose of “professional modesty.”
In other words: forget, for the time being, your knowledge of anatomy, physiology and pathology! Tilburt’s recommendations, however, are practical: commence CAM research with ailments for which normal medicine does not, supposedly, have much to offer, such as low back pain. Also, the traditional use of herbs could be an indication of efficacy and is worth some research.
Tilburt also advises research of the placebo effect, even for CAM treatments from which no biological effects can be expected. In that case a CAM treatment can be compared with no treatment, even if the therapist and the patient both strongly believe in the value of the CAM treatment. If this kind of research shows positive results, then accepting this—according to Tilburt—requires a medical pluralism that ‘stretches a researcher’s conception of benefit in an open-minded and pragmatic way.’
This is a discouraging book that presents a rather shocking view of the socio-cultural setting in which doctors in the USA seem to be trained and must perform their work. Never contradict patients, because then they walk away and that costs money. Respected institutions like Johns Hopkins, Harvard, and the University of New Mexico conform to that philosophy and are not prepared to speak a clear language. Their medical students will consider respect for and even cooperation with CAM practitioners as normal, instead of what it is: an anomaly!
The US spends an enormous amount of money on healthcare, considerably more per capita than, for instance, the Netherlands, while at the same time tens of millions of US citizens are uninsured. The government subsidizes the NCCAM with something like $120 million per year for its search for effective quackeries. As Dutchmen perhaps we should be glad that our government squanders only something like €190,000 on such purposes—this was considered so outrageous that in 2007 the Dutch Society against Quackery awarded that scheme the ‘Master Kackadoris Prize,’ its annual highly-feared recognition of someone furthering quackery. But how can we possibly complain if matters are so much worse in the USA? From reading Snyder’s book your reviewer concludes that in the USA, such a prize could be awarded every month.
Cees N. M. Renckens, M.D., Ph.D., works as a gynaecologist in the Westfries Gasthuis in Hoorn, with a special interest in infertility and endocrinology. Since 1988, he has been the chairman of the Dutch Society against Quackery, which at present has a membership of approximately 1850. He is the author of many publications on quackery and alternative medicine, mainly in Dutch. He has written three books: Contemporary Quackery (1992), Quacks in Potassium Hydroxide (2000) and It Cannot be Called Healing. Sketches of the Twenty Most Notorious Healers of the 20th Century (2001). At the University of Amsterdam in 2004, he successfully defended his thesis, “Wrong Tracks in Medicine,” which discussed alternative medicine, fashionable disorders, and quackery.
Some recent publications in English are:
- Between hysteria and quackery: some reflections on the Dutch epidemic of ‘pelvic instability’. J Psychosom Obstet Gynecol 2000;21:235-239.
- Alternative treatments in reproductive medicine: much ado about nothing. Human Reproduction 2002;17, 528-533.
- A Comparison between Alternative Pseudodiagnoses and regularly Accepted Fashionable Diseases: An analysis Prompted by the Dutch Epidemic of Obstetric “Pelvic Instability.” The Scientific Review of Alternative Medicine. 2002, vol 6 (2): 91-96.
- The sharp end of medical practice: the use of acupuncture in obstetrics and gynaecology. (Letter to the Editor). Br J Obstet Gynaecol 2002, 109: 1418-9.
- Proving the unlikely: trials in alternative medicine. Focus on Alternative and Complementary Therapies. 2003,8(3):307-308.
- Hysterectomy and bilateral oophorectomy for severe premenstrual syndrome. Hum Reprod. 2005 Apr;20(4):1113-4. (Letter to the Editor).
- Beware of quacks at the WHO. Cees N.M. Renckens, Tom Schoepen, Wim Betz. Skeptical Inquirer 2005, Vol 29, no 5:12-14.
- A case of virilisation of initially obscure origin in a postmenopausal woman. C. N.M. Renckens, F.M. van der Zant MD, M.F. Hasper en J.W.D. de Waard. BJOG 2006;113:125-126.
- On editors, Auditors and the Science Police: Some reflections on the Cha-Wirth-Lobo Affair. The Scientific Review of Alternative Medicine. Vol 10, 2006. pp. 45-56
- Stephen Straus (1947-2007): an obituary and some second thoughts on research priorities. HealthWatch Newsletter, No 69, April 2008: 7