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Pharmacists Selling Snakeoil

snake-oil

Edzard Ernst published an excellent editorial today addressing the question of why pharmacists sell bogus products. Our own resident pharmacist, Scott Gavura, expressed similar points here on SBM a year ago. Their points are worth emphasizing and expanding upon.

Professional ethics

The explicit premise of both editorials is that pharmacists, like physicians, are health care professionals. Being a professional means adhering to certain professional standard of quality control and ethical behavior. A profession is essentially a contract with society – the profession gets exclusive rights to certain commercial behaviors, and in return promises to maintain adequate quality control and to act in the best interests of society and their individual clients.

When a profession puts their own commercial interests ahead of society or their individual customers, they have violated that contract.

There are multiple layers of regulation to maintain quality and ethical standards in the health care professions. Once a profession is licensed, they basically self-regulate, with members of the profession establishing the standard of care. Standardized testing designed by the profession is used to establish competence or specialized expertise.

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Posted in: Science and Medicine

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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.

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Posted in: Health Fraud, Medical Ethics

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CRISPR and the Ethics of Gene Editing

CRISPR-conf

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?

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Posted in: Ethics

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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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Placebo by Conditioning

power-of-placebo-effectTruly understanding placebo effects (note the plural) is critical to science-based medicine. Misconceptions about placebo effects are perhaps the common problem I encounter among otherwise-scientific professionals and science communicators.

The persistence of these misconceptions is due partly to the fact that false beliefs about placebos, namely that “the” placebo effect is mainly an expectation mind-over-matter effect, is deeply embedded in the culture. It is further exacerbated by recent attempts by CAM proponents to promote placebo-medicine, as their preferred treatments are increasingly being demonstrated to be nothing but placebos.

One idea that proponents of placebo medicine have tried to put forth is that you can have a placebo effect without deception. The study most often pointed to in order to support this claim is Ted Kaptchuk’s irritable bowel syndrome study. However, this study was flawed in that it told participants that placebos can heal, so it wasn’t exactly without deception. (more…)

Posted in: Medical Ethics, Science and Medicine

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In which I steal a title: Is medicine a scientific enterprise?

Abraham Flexner (left) and Richard Dawkins (right): Enemies of medicine?

Abraham Flexner (left) and Richard Dawkins (right): Enemies of medicine?

A week ago, I attended the Center For Inquiry Reason for Change Conference, where I participated in a panel on—what else?—alternative medicine with—who else?—Harriet Hall and our fearless leader Steve Novella. Before the panel, we all gave brief talks on areas that we consider important. As you might expect, I chose to give a brief introduction to what I like to call “quackademic medicine,” defined as the pseudoscientific medicine being practiced and studied in academic medical centers. As I like to do in order to drive the point home about just how bad it’s become, I chose a couple of truly egregious examples of just how much quackery has infiltrated medical academia. First, I mentioned how the Cleveland Clinic has embraced reiki, which, as I’ve described many times before, is in reality faith healing that substitutes Eastern mysticism for Christian beliefs. Although I could have buried the audience in examples, the other example I happened to choose was this:

Yes, that is exactly what you think it is. It’s the official Twitter account of the Mayo Clinic promoting “energy therapies,” of which reiki is one of the most popular varieties. Basically, these are “therapies” in which it is claimed that the practitioner can either (1) manipulate the “life energy” fields of the patient (e.g., healing touch) or (2) channel “healing energy” into the patient from a source (e.g., reiki). And here was the Mayo Clinic promoting this magical mystical nonsense, linking to an article on its official website entitled “Energy Therapies Offer Support in Healing for Cancer Survivors“: (more…)

Posted in: Science and Medicine

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Stem cells versus Gordie Howe’s stroke, part 2

Gordie-Howe

Another Christmas has come and gone, surprisingly fast, as always. I had thought that it might make a good “last of 2014” post—well, last of 2014 for me, anyway; Harriet and Steve, at least, will be posting before 2014 ends—to do an end of year list of the best and worst of the year. Unfortunately, there remains a pressing issue that doesn’t permit that, some unfinished business, if you will. I’m referring to a story I commented on last week, specifically the credulously-reported story of how 86-year-old hockey legend Gordie Howe is doing a lot better after having undergone an experimental stem cell therapy for his recent stroke. As you might recall at the time, I saw a lot of holes in the story. It turns out that over the last week there have been developments that allow me to fill in some of those holes. Unfortunately, other holes still remain.

First, a brief recap is in order (You can click here for a more detailed timeline). Gordie Howe suffered a massive stroke on October 26, leaving him hemiplegic and with serious speech impairment. Since then, judging from various media reports, he has been slowly improving, although not without significant setbacks. We also know that Howe suffers from significant dementia. Out of the blue, a press release issued on December 19 by the Howe family announced that on December 8 and 9, Gordie Howe “underwent a two-day, non-surgical treatment at Novastem’s medical facility. The treatment included neural stem cells injected into the spinal canal on Day 1 and mesenchymal stem cells by intravenous infusion on Day 2.” His response was described as “truly miraculous,” although, as I pointed out in my post, it’s not clear exactly what “miraculous” meant, given conflicting contemporaneous news accounts before the Howe family press release, particularly his hospitalization from December 1 to 3 for a suspected stroke that turned out to be dehydration.

I noted a number of problems with the story, the first of which is that Howe was clearly not eligible for the clinical trial offered by Stemedica, a company in San Diego that manufactured the stem cells used. Another glaring issue was my inability to locate any description of an actual clinical trial for stroke offered by Novastem. I could find no such trial listed in ClinicalTrials.gov, and you, our intrepid readers, searched the registry maintained by the Mexican Federal Commission for the Protection Against Sanitary Risk (COFEPRIS) and were not able to find any registered clinical trials for stroke being carried out by Clínica Santa Clarita, the clinic Novastem operates. What you, our intrepid readers, did find were trials of stem cells for:

I did the search again over the weekend, and there were no further trials that I could find.
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Posted in: Clinical Trials, Medical Ethics, Science and the Media

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Science-Based Medicine Meets Medical Ethics

There are four main principles in medical ethics:

  •  Autonomy
  •  Beneficence
  •  Non-maleficence
  •  Justice

Autonomy means the patient has the right to consent to treatment or to reject it. Autonomy has to be balanced against the good of society. What if a patient’s rejection of treatment or quarantine allows an epidemic to spread? Beneficence means we should do what is best for the patient. Non-maleficence means “First do no harm.” Justice applies to conundrums like how to provide kidney dialysis and organ transplants equitably in a society that can’t afford to treat everyone with expensive high-tech treatments or where the rich can afford better treatment than the poor.

Medical ethicist Ronald Munson has written a fascinating book entitled The Woman Who Decided to Die: Challenges and Choices at the Edges of Medicine. His clinical vignettes vividly illustrate the difficult decisions that must be made when science-based medicine runs up against the harsh practical reality of ethical dilemmas. (more…)

Posted in: Book & movie reviews, Medical Ethics

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Between a Rock and a Hard Place: A Case Study Exploring the Battle Lines of Science Based Medicine

Editor’s Note: This is a guest post solicited by Dr. Hall, who describes Dr. Albietz thusly: He’s a skeptical young pediatrician who works in a PICU and recently had a chiropractor come into the PICU to consult on a child with intractable seizures. He was sort of coerced to allow this at the parents’ request and against his better judgment. His hospital had set a precedent of letting alternative practitioners have temporary privileges in cases like this. He was torn between his academic integrity and doing the most humane thing for the patient and family.

Primum non nocere.” First, do no harm. It is a guiding principle of medicine, and one which is next to impossible to achieve in practice. It is difficult for the general public to hear, but any intervention a physician makes, and indeed the decision to make no intervention, carries a risk of harm with it. Given enough time, every physician will make a decision which results in unintended harm to a patient, even death, and it haunts us every day of our careers. Faced with this horrible certainty, what is one to do? The only responsible, ethical position to take is to ensure that each patient receives the care most likely to generate a positive outcome, in other words, to stack the deck as steeply in favor of the patient as is possible. Diligent application of the scientific method to every therapy, novel and new, old and venerated, is the only way we as physicians can be certain we are doing the greatest good and the least harm to those who seek our help; it is the only way to assuage our conscience if things end badly.

Our professional organizations and academic institutions have been vital in formulating, propagating, and enforcing the practice of evidence based medicine (EBM). They have stood, to borrow the phrase from Carl Sagan, as “a candle in the dark,” promoting the best practices and protecting patients from those that are ineffective, fraudulent, harmful, or even simply sub-standard. It is a heartening environment in which to work.

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Posted in: Chiropractic, Medical Ethics

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Does alternative medicine have alternative ethics?

Kimball Atwood has an interesting series of posts on the ethics of alternative medicine which I strongly encourage you to read.  He does a great job examining the ethical implications of certain alternative medicine practices, and has a terrific dialog with Peter Moran, a frequent commenter here.   At my other online locale, I make frequent forays into the morass of medical ethics, with an emphasis on specific clinical scenarios.  Today, though, I’d like to take a step back and examine the nature of medical ethics as they apply to so-called alternative medicine.

First, and perhaps most important, I am not an ethicist.  I do not have the depth of reading, the knowledge of terminology, or the specific education to lead a formal discussion on ethics.  What I am is a practicing internist, who must make ethical decisions on a daily basis. Most of these decisions are of necessity made “from the heart”, but it is not infrequent that I must evaluate a situation more formally and fall back on some of the ethical principles of my profession.

Ethics are not static.  They are not a divine gift bestowed on each of us as we don our white coats.  They are a living part of our specific cultures, and of the profession we serve.  Some of the modern principles of medical ethics are newer than others.  Beneficence, non-maleficence, and confidentiality are ancient principles of medical ethics, which continue to be relevant today.  Patient autonomy is a more recent value, reflecting a shift in how society views the relationship between patient and physician.  These ethics must be mutable, as the profession itself is ever-changing.  Despite this fluidity, there is an identifiable line of “doctor-hood” that has existed for at least the last century, and the members of this guild have always tried to adhere to some type of code of behavior.

Alternative medicine poses real challenges to the principle of medical ethics.  First, we’ll discuss who, in fact, is bound by these principles, then the way in which alternative medicine is or is not compatible with medical ethics. (more…)

Posted in: Medical Ethics, Science and Medicine

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