Respectful Insolence

A few days ago, I posted a response to another physician who was not happy with me, no, not happy with me at all. What made him unhappy was the vociferousness with which I criticized the creeping infiltration of woo that is insinuating itself into medical school curricula and expressed dismay at the threat that I see to evidence-based medicine (EBM) from it. He interpreted this vociferousness as “anger,” but in reality it is more frustration, a dismay that was exacerbated by his defense of including unproven therapies in his practice. I did not respond so harshly somuch because I think that in his specific case his use of acupuncture does harm, but rather because of the attitude behind it, an attitude that can (and in too many cases does) open the door to less benign forms of woo.

At the risk of turning this into the Solo Practitioner rebuttal blog, I thought I’d have one more go at it because of one further comment he made. SP’s misguided analogy does, almost in spite of itself, bring up a a difficult issue, although I resent it a bit that he did so in the context of labeling me and those who have little tolerance for woo as “fanatics”:

Let’s talk about false hope. Apparently “conventional” medicine is immune from providing this to its patients; however, a study a few years ago found that less than 50% of terminally ill patients with cancer at one of the nation’s leading cancer centers, Memorial Sloan-Kettering Cancer Center, were approached with discussions about end-of-life issues, such as a DNR (Do Not Resuscitate) order and a Living Will. Furthermore, most of the therapies used for terminal cancer patients at MSKCC are not EBM, because there hasn’t been enough time to study the efficacy of these therapies, or perhaps because these “conventional” doctors have decided that there is little “harm” that can be done with potentially toxic chemotherapy if the person is going to die anyway (as long as the patient consents to a potentially toxic, life-threatening treatment. But what would make a patient consent to such an unproven treatment? Could it be that it provides some hope of a cure?). It seems these doctors believe that they can try experimental, unproven therapies because these patients come to them from other referral centers where their cancers were determined untreatable. These patients are coming for another answer and for HOPE. So are these doctors at MSKCC “quacks” for slipping outside the confines of EBM to try to help the terminally ill? According to Orac, it sounds like no other medicine should be practiced other than EBM.

“Sorry, you’ve got Stage IV Ovarian CA, go home, get your affairs in order and die, because there are no evidence-based treatments that work,” is perhaps what they should tell their patients. That way we’re all living in realityland. How is it ok for “conventional” medicine to expose these patients to harmful, toxic treatments that are unproven? It doesn’t stand up according to Orac’s arguments.

Logical fallacies piled on top of nonsequiturs piled on top of straw men. These have to be dealt with before we get to the issue that he brings up almost by accident, namely the ethics of clinical trials in which terminally ill cancer patients are enrolled.

Let’s start with the tu quoque logical fallacy, which basically means “nah, nah, nah, you too!” Fine, I’ll concede that conventional medicine often does not do a good job of dealing with end-of-life issues. In fact, I’ll even go SP one further, even if it is at the risk of offending my fellow ScienceBlogger The Cheerful Oncologist, and tell an oncologist joke that goes along these lines:

“Why is it a good idea to nail shut the coffin of a cancer patient who’s died?”

“To stop the oncologist from trying to give him more chemo.”

OK, it’s a bad joke, but it has a point, which is that there is a subset of oncologists who never give up and keep treating hopeless cases, rather than facing reality and changing the focus to palliative therapy, to trying to make the patient’s remaining time as comfortable as possible. Not infrequently are the times when I’ve been consulted on a patient with metastatic cancer and a bowel obstruction due to peritoneal carcinomatosis (in essence, a belly full of tumor lining the peritoneal membranes covering the abdominal organs) who is clearly at death’s door to be considered as a surgical candidate, despite the fact that in a patient in such a debilitated state surgery has only a very small chance of accomplishing even the palliative goals of enabling him to eat solid food again, and the morbidity and mortality due to surgery are high. Patients operated on under such circumstances seldom make it out of the hospital alive, and they often suffer many complications before they die, observations that suggest that a very selective approach is called for in choosing whom to operate on. (I discussed this very issue in one of my very first blog posts.) It’s also been a not infrequent occurrence over the years that such patients often do not have “do not resuscitate” orders that clarify what level of care they want (full code, ICU transfer, intubation, medication drips to support their blood pressure, etc.) if they should suffer a cardiac arrest, leaving me in the awkward position of having to broach the topic with a patient whom I’ve never met before in the context of discussing what surgery can (or, more frequently, cannot) do for him. Most of the oncologists that I’ve work with range from pretty good to fantastic at addressing these issues, but not always, and sometimes even the great ones don’t settle the issue because the patient isn’t ready to discuss it.

Of course, just because conventional oncologists more often than we like do not do a great job at dealing with end-of-life issues, however, is not an argument against EBM or for woo. That’s a nonsequitur. That conventional oncologists could do better with end-of-life issues is an argument for finding ways to get physicians to do better in that area within the context of EBM. That should be, but apparently isn’t, obvious to SP. Doesn’t he realize that quacks who prey on terminally ill cancer patients do a far, far worse job of dealing with end-of-life issues than even the most incompetent conventional oncologist? Indeed, quacks deal with end-of-life issues, in essence, by ignoring them entirely. After all, discussing the possibility of the patient’s death would require admitting to the patient the possibility that their treatments won’t work, something we as physicians ethically must do but quacks don’t. Given that the quacks’ sales pitch is that they can cure cancers that conventional medicine cannot, discussing end-of-life issues is bad for business. In any case, it’s a straw man to claim that I advocate telling terminally ill patients to “get their affairs in order and die” in a manner as callous as described. Just because a cancer is no longer curable does not mean that it is no longer treatable or that effective palliation does not exist. SP seems to be a victim of all-or-nothing thinking; either a physician treats for cure or he is telling his patient to go home and die (that is, it would seem, while he isn’t busy preying on the patient’s hope by experimenting on him with toxic chemotherapy). Whether he realizes it or not, SP is in essence using the failures of EBM-practicing physicians in counseling patients as a defense of cancer quackery.

In fact, SP’s nonsequitur/tu quoque combination really irritated me. (If it didn’t, I wouldn’t have responded with a second blog post to his ramblings.) SP actually makes an analogy between the hope that patients entering clinical trials of new cancer medications have and the “hope” that quacks give such patients, implying that there’s no real difference and that physicians offering experimental therapeutics to terminally ill cancer patients are somehow going outside the bounds of evidence-based medicine. He’s astoundingly incorrect, of course, when he seemingly implies (actually, all but states explicitly) that oncologists at Memorial Sloan-Kettering Cancer Center who use experimental treatments on terminally ill cancer patients prey on patients’ hope the same way that quacks do.

The reason why is just as obvious as why his tu quoque rhetoric was a logical fallacy. It’s a little thing called informed consent. Before a patient who meets the enrollment criteria and doesn’t meet any of the exclusion criteria is enrolled in a clinical trial of an experimental therapy, several things have to happen: (1) what is known and not known about the therapy being tested has to be explained in detail to the patient in lay terms; (2) the risks, as far as they are known, have to be described; (3) the patient has to read and sign a detailed informed consent form without duress, signifying his or her agreement to participate and understanding of the protocol and risks. In fact, before such a study can even be opened to patient accrual, it first has to pass two committees, the Scientific Review Board (SRB), which looks at the scientific design of the proposed trial to verify that it tests an important question and that the design is scientifically sound; and the Institutional Review Board (IRB), which verifies that the protocol does not subject patients to undue risks compared to its potential benefits, that it provides truly informed consent, and that it does not subject the patient to undue pain (excessive blood draws, invasive tests, etc.). Finally, clinical trials are not somehow outside the rubric of EBM because the very rationale for them must be based on sound preclinical scientific evidence, often coupled with small amounts of clinical data (case reports, small case series) that suggest that the therapy being tested might be efficacious.

I think you can see the difference between a clinical trial as described above and how quacks operate. Quacks promise desperate patients for whom no curative therapy is available from “conventional” medicine that they will be cured with little pain or suffering, even though there is no evidence to support such claims. Consider the Hoxsey treatment, which its main adherents claim to be able to cure 80% of patients with cancer who take it. Of course, if it didn’t work, Mildred Nelson, who took over the BioMedical Clinic in Tijuana after Harry Hoxsey died, would blame it on the patients, saying the patient “didn’t believe enough” in the treatment. And that’s just one example. There are many, many more.

Still, even though SP’s intent in what appears to me to be a criticism of MSKCC for abusing patients’ hope seems to be to imply by comparison that woo isn’t so bad because it gives hope, almost by accident he manages, in spite of his bad arguments, to raise an important issue; i.e., the ethics of clinical trials on terminally ill cancer patients. We do indeed have to be careful about using hope to sell new drugs in clinical trials. I would argue that this is not so big a problem in Phase III clinical trials. These are large randomized studies enrolling significant numbers of patients, in which a new drug is compared with the standard of care. (The reason that new drugs are compared to standard of care rather than placebo in phase III oncology trials is because, under most circumstances, it would be unethical to treat a cancer patient with a placebo.) Both groups are getting what is viewed as effective therapy, because a drug wouldn’t make it to a phase III trial if it didn’t show evidence of efficacy in Phase I and Phase II trials.

More care has to be taken in Phase I trials. Phase I trials usually represent the first time that a drug is ever given to human beings. The patients enrolled almost always have terminal cancer for which no further potentially curative therapies are known. It has to be remembered that the purpose of a phase I trial is not to determine if a drug is effective against cancer, but rather to evaluate its safety, determine the maximal tolerated dose, and measure toxicity. It’s nice if tumor shrinkage is observed, but not essential for the drug to be taken to the next stage, phase II trials. It’s true that patients enroll in these studies because they have some hope that they might be helped by the drug being tested. However, IRBs are very insistent that it must be emphasized to patients enrolling in phase I trials that they are unlikely to benefit from the new drug.

So, knowing this, why do patients enroll in phase I trials? Certainly, altruism is one major reason, the desire that their deaths have meaning in contributing to knowledge that might help future patients. Also, as this editorial explains, as long as careful respect for patient autonomy and informed consent is maintained, phase I clinical trials are not unethical, nor do they abuse a patients’ hope:

Investigational drug trials are ultimately the result of a complex scientific and ethical balancing act very familiar to the investigators involved in the studies that Dr Slyter cites. It is unfortunate that new treatments cannot be developed without risk, but we do not believe that the principle of “do no harm” should be translated into “make no attempt to help unless risks can be eliminated.” Virtually all forms of treatment involve risks. A physician’s role is to try to assess the benefit-to-risk ratio. Most commonly accepted therapies can have side effects ranging from serious injury to death, and many patients do not respond to a given form of treatment. If avoiding harm was the only objective of physicians, it would be a logically defensible position that we should not treat anyone.

The purpose of a phase 1 trial is not to prove the efficacy of a new agent, and one can predict with near certainty that some patients will suffer adverse events. This is inevitable in almost any drug development program, because the tolerability limits of a new form of treatment must be explored to define its safety profile. Initial estimates are derived from preclinical testing, but the final determination must come from human studies. It is not more ethical to expose healthy volunteers to potential side effects than to conduct these trials in patients who have at least the possibility of benefit from the investigational agent…

The potential for drug-induced injury must be explained to prospective study patients in a manner that is specified and approved in advance of the trial. These plans are reviewed by institutional review boards (IRBs) that include physicians who are not directly involved in the clinical testing, as well as other patient advocates. It is, however, impossible to inform patients fully of the risk-benefit ratio during a drug development trial, since that information is derived ultimately from the entire drug development process. If a patient does not wish to assume unknown risks, he or she can simply refuse to participate in a trial, and many do.

The difference between a well-designed clinical trial and quackery in terms of dealing with patient hope and expectations could not be clearer. Yes, like any human endeavor, clinical trials are not always carried out according to the ideal, and, because doctors are human, sometimes oncologists will sell such trials by playing up the possibility of patient benefit more than is warranted. But contrast this with quackery, where no attempt to be realistic about the risks and the possibilities of benefits is even made, and I think you’ll see just how inappropriate SP’s analogy is. It’s a shame that SP is so persistent about defending woo and seems fairly hostile to EBM, because he actually does have other things to say that are interesting, such as his description of how insurance companies sometimes stealthily try to cut reimbursements to physicians without notice. On the other hand, his reading list, which includes books like Deepak Chopra‘s Quantum Healing, and you know what I think of Dr. Chopra. (Maybe his referring to himself as “Shaman” or “Medicine Man” is not meant entirely ironically.) I just wish that SP would apply the same level of critical thinking skills to the evaluation of alternative medicines and his perception of the evils of conventional medicine as he does to chicanery by his insurance company.

Comments

  1. #1 BigHeathenMike
    November 22, 2006

    Great piece. You’re right on the money, in that if woo “treatments” put in the effort to do proper testing and evaluation before thumping the tub and sticking needles in people, we’d see a lot less of that stuff. You know…because it doesn’t work.

    We have to realize that things like acupuncture do seem to work sometimes for pain. Pain, however, is highly placebo-responsive and the fact that acupuncture is “thousands of years old” and from a land far away makes for a great story to be believed. The point is, if it’s your belief that is making the “treatment” effective, then the “treatment” is irrelevant. If I can convince you that drinking glacier water from a fedora hat with a ripe plum floating in it will make your back stop hurting, and you believe me, it’ll probably work for a while.

  2. #2 Bronze Dog
    November 22, 2006

    If I can convince you that drinking glacier water from a fedora hat with a ripe plum floating in it will make your back stop hurting, and you believe me, it’ll probably work for a while.

    Sounds like you’ve been hanging out with Barney’s girlfriend from his Bee Sharps days. You know, the one who looked kind of like Yoko Ono.

    Barney: “I’d like a beer.”

    Girlfriend: “I’d like a single plum, floating in perfume, inside a man’s hat.”

    Moe: *pulls out the already prepared items from under the bar* “Here you go.”

  3. #3 Blake Stacey
    November 22, 2006

    My grandfather died of cancer when I was in elementary school. Other relations and family friends have had medical problems, too, some of them ending lives far before any time one could call “natural”. To claim as alties do that decent people like these died “because they did not believe hard enough” is an insult to their memory. Not only is it scientifically unfounded, but it is also morally repugnant.

  4. #4 Clark "ad hominem" Bartram
    November 22, 2006

    Is the fact that he has a link to Chopra’s Quantum Healing under his recommended readings list enough to call this guy a quack? Also he seems to have an affinity for “Life Coaching”. Now that doesn’t have anything to do with the q-word but it should serve as a big red flag.

  5. #5 Terry Harding
    November 22, 2006

    Great post as always, but I find myself somewhat bothered by your general terminology. As a general science fan with an educational background in geology rather than medicine, I read you for entertainment and education, but also to get help in debating/discussing these issues with people who believe in this stuff.

    Frankly, I don’t want to insult a person I am trying to swing away from pseudoscience and the terms “evidence based medicine” and woo are just plain insulting to a large percentage of them. I suggest that “science-based medicine” is a better term.

    I see two types of pseudoscience out there. There is, of course pure woo such as homeopathy and the really extreme stuff you report on in your “Friday Dose Of Woo” posts. This stuff is clearly not evidence based in any way and qualifies as pure dog poo somebody just made up. There is another class however, which I call the CAMers. While it is still unscientific and even anti-scientific is not totally woo based. This is the Andrew Weil type of stuff. Yes, he throws in a lot of pure woo, but most of what he says both he and his followers would call evidence based. Rather than just making it up as they go, they use a combination of anecdotal evidence and very selective and uncritical reading of actual studies.

    I certainly agree that both the woosters and the CAMers are destructive to popular understanding and acceptance of science-based medicine, but I also feel that you need to differentiate between them in your terminology.

  6. #6 Blake Stacey
    November 22, 2006

    @Terry Harding:

    You draw an interesting distinction between “woosters” and “CAMers”. Do you think this is analogous to the division between, say, Young-Earth Creationists and Intelligent Design Creationists?

  7. #7 BigHeathenMike
    November 22, 2006

    Bronze Dog:
    Yeah, that was quite close to the ‘Yoko’ character’s line, wasn’t it? Man, that was a good episode. I still sing, as Barney did on the floor of the bathroom in Moe’s, The Irish Lullaby from time to time. I don’t do it on the bathroom floor, however.

  8. #8 Infophile
    November 22, 2006

    The point is, if it’s your belief that is making the “treatment” effective, then the “treatment” is irrelevant.

    One of them actually said this to me once. I’d gone to see an acupuncturist for my allergies at my father’s urging. I was convinced it wouldn’t work, but sometimes there’s no arguing with that man.

    So, I asked her how it was supposed to work, and at one point she said to me, “It only works if you believe it works.”

    I replied, “Well, then I don’t believe it works, so you must agree it won’t work,” and left.

  9. #9 Sara
    November 22, 2006

    WHile I agree about the basic difference between Alties, and despise the woomeisters who hold out false hope and profit from the fear of the dying…. I must say this.

    My grandmother, in the early 90s, was diagnosed with colon cancer, metastasized to the liver.

    She elected to go to our state’s Big University Medical Center, affiliated with their prestigious medical school. She enrolled in clinical trials. I visited her there repeatedly.

    And there I saw repeated examples of spin and half-truths in pursuit of “informed consent” that would make Karl Rove stand up and take note. I suppose never did an outright lie actually leave anyone’s mouth, but through selective editing and refusing to answer direct questions, you can accomplish the same thing and stay “just* this side of ethics laws. It was disgusting. Med students and residents sometimes have almost as big a motive as profit to manipulate dying people — publications and procedure counts.

    To be fair, my uncle has since spent a lot of time at the same Prestigious Medical School, and has been involved in several research projects. All of them have been straightforward and treated him with respect. His cancer is of a different type; I can’t say whether the differences I see are differences in research programs and the PIs who run them — or whether its the difference between dealing with a 74 year old woman with a high school education vs. a 50 year old man who taught high school science for 30 years.

  10. #10 Dianne
    November 22, 2006

    It’s true that patients enroll in these studies because they have some hope that they might be helped by the drug being tested.

    I don’t think that this is the whole story. While I’ve never seen a patient not want to be helped by the trial he or she participates in, I think that frequently the primary motivation is altruism: the hope that the researchers will learn something through the trial that will, someday, help others even if it doesn’t help the patient him or herself.

  11. #11 AgnosticOracle
    November 22, 2006

    Really good discussion. The one thing that made me wonder was if this might be its own straw man attacking our stereotype of quacks instead of what is really out there.

    So I did a google search for “alternative medicine cancer cure.” The two paid ads go to:

    http://www.envita.com/conditions/cancer/landing/cancer.htm
    http://www.immunemedicine.com/

    They are indeed all salesmanship and testemonials, no informed consent there.

  12. #12 Renee
    November 22, 2006

    Re the issue of informed consent and clinical trials –

    During the informed consent discussion, are the benefits and drawbacks of participating in a clinical trial discussed in simple language? I mean a discussion with the points listed like those below, which comes from the website for the women’s magazine ‘More’. (http://more.com/more/story.jsp?storyid=/templatedata/lhj/story/data/bc_clinicaltrial_09132004.xml)

    “The National Cancer Institute lists the following benefits and drawbacks of joining a clinical trial.

    Possible benefits

    1. Clinical trials offer high-quality cancer care. If you are in a study and do not receive the new treatment being tested, you will still receive the best standard treatment. This may be as good as, or better than, the new approach.
    2. If a new treatment approach is proved to work and you are taking it, you may be among the first to benefit.
    3.You have the chance to help others and improve cancer treatment.

    Possible drawbacks

    1. New treatments under study are not always better than, or even as good as, standard care. They may have side effects that doctors do not expect or that are worse than those of standard treatment.
    2. Even if a new treatment has benefits, it may not work for you. Even standard treatments, proven effective for many people, do not help everyone.
    3. Health insurance and managed care providers do not always cover all patient care costs in a study.”

    It seems to me that the time to have this discussion is when a patient first brings up the subject of clinical trials with his/her oncologist, or when the oncologist first brings it up. I don’t think it should be when the patient is already meeting with the person trying to enroll him/her in the trial. Like the poster above commented, at this point, the patient may feel under some pressure to join the trial, even if the pressure is well meant.

    Even if the patient themselves understands the risks and benefits of a trial, there’s the possibility that their families and friends won’t. What the latter will see is that the patient is still receiving treatment, and so naturally there must be some hope that the patient will survive. Why else would someone undergo treatment?

    I’ve run into this problem myself, when my brother tried to sign my elderly father up for a trial of a potential drug for Alzheimer’s. My brother was under the impression that this was a proven treatment, and that my father would get this proven treatment sooner than other people. My brother had already called the enrollment person and set up an appointment for my father to be evaluated. The enrollment person neglected to ask if my father had been diagnosed with Alzheimers (he hadn’t) or if my father had anything that interfered with his abilities to reason or remember things (he did, he’d had a stroke). Two automatic exclusion criteria, which I used to disenroll my father from his evaluation.

    I believe that amongst the general public, there is a widespread misunderstanding of what clinical trials are for, what the different types of trials are, and what they have to offer (or not) to patients. Even my brother, with an MS in computer science and an MBA, was mixed up about these issues.

  13. #13 Joe
    November 22, 2006

    Orac, this is an excellent post. Thanks.

    @Terry Harding,
    It does not matter if Weil thinks anecdote is evidence, he is wrong. There’s no two ways about it. Look at this discourse on Weil:
    http://www.quackwatch.org/11Ind/weil.html
    EBM is just that, the plural of “anecdote” is not “evidence” and we don’t need to mollycoddle people who don’t understand this. Especially, not Weil. Also look at this review of his latest book:
    “Andrew Weil: Harvard hatched a gullible guru.” Weil’s book “Natural Health, Natural Medicine” reviewed by Harriet Hall (M.D.). “Skeptical Inquirer” 30:1 (Jan-Feb 2006), p56:
    “[This] is a dangerous book. The preface states: “All the information is consistent with the best scientific evidence currently available.” This is simply not true. The information is a promiscuous mix of good science, unsupported opinion, and superstition, with no clues as to which is which.”

    Also from her review:
    “His advice about rheumatoid arthritis is not only foolish but dangerous. He recommends avoiding prescription drugs, but research has shown that early treatment with disease-modifying drugs can change the course of this disease. If you waste time trying home remedies, you may miss the chance to prevent crippling deformities.”

    @Blake Stacey,
    Robert Pennock wrote a book about ID, “The Tower of Babel.” FYI, the idea is that creationists of all stripes could rally behind ID; while arguing viciously among themselves in the background- over young vs. old Earth.

    Although your specific analogy may be innacurate in practice, it is, nonetheless, taken well. Duelling woo, so to speak. Yes?

  14. #14 SP
    November 22, 2006

    Orac wrote: “SP seems to be a victim of all-or-nothing thinking; either a physician treats for cure or he is telling his patient to go home and die (that is, it would seem, while he isn’t busy preying on the patient’s hope by experimenting on him with toxic chemotherapy). Whether he realizes it or not, SP is in essence using the failures of EBM-practicing physicians in counseling patients as a defense of cancer quackery.”

    Wrong. Merely pointing out that there are three fingers pointing back at you when one is pointing at the other person. I am not writing a defense of CAM or opposing EBM. You have not read carefully if you can’t see that I am actually opposing all or none thinking. I’m merely proposing a more checks-and-balances style of thinking with which everything should be evaluated. The previous posts and the followers of this blog, don’t seem to point out any of the weaknesses of EBM and “conventional” medicine while burning CAM at the stake. I am merely providing the counterpoint.

    Clark Bartram wrote: “he seems to have an affinity for “Life Coaching”. Now that doesn’t have anything to do with the q-word but it should serve as a big red flag.”

    Clark, it’s a shame if you are not familiar with life-coaching, which is a form of proactive therapy which has helped many of my patients. Not everyone is a good fit for conventional psychotherapy. Now I don’t know what you do, but I’d love to know what you know about life-coaching to call it a big red flag?

  15. #15 Clark Bartram
    November 22, 2006

    I’m a life coach.

  16. #16 Justin Moretti
    November 22, 2006

    > How is it ok for “conventional” medicine to expose these patients to harmful, toxic treatments that are unproven?

    In asking this question, you seem to miss the point. The issue is not that the treatment is harmful or toxic but that the alternative (death) is worse.

    Conversely, in trying to do no harm (quackery), you risk doing no good.

    Neither Orac nor any other anti-quack really gives a stuff WHAT you put in a patient’s body. All we really care about is that you apply the same rigor to the pre-treatment diagnostic workup and post-treatment assessment of efficacy; that you know exactly what you are putting in and how much; that you have excluded impurities and confouding factors; that you have a plausible mechanism for what you are doing before you even start; and that you are willing to be brutally honest about your failures and report the patients who died.

    It’s not what the quacks are doing that offends us, so much as the way they go about it. They demand ultimate accountability from us and keep dodging it themselves on every level, from the theoretical to the end analysis of treatment groups and acceptance of/blame for their stuff-ups. From this viewpoint, “CAM” should not only be burned at the stake; it should be violated in Hell by demons who shriek their glee to the skies.

    The sooner the US nationalises its health system, the sooner we will see an end to this, simply because the poor victim won’t be left to choose between a horrendous cost for what THEY know didn’t work for their parents or grandparents (but we know works better now) and the siren-like lure of quackery which is cheaper and promises ‘no harm’ but does nothing except allow progression of their disease, while in some cases blaming the patient for the inevitable disaster and providing no data whatsoever on progression, regression etc. etc that might be learned from.

    When I see a quack medical journal reporting a string of failures with carcinoma en cuirasse in females with breast lumps, an analysis of reasons for failure that doesn’t place the blame on the patient, and a recommendation not to try this one again, then I will take “CAM” seriously.

    FYI my attitude to a patient with incurable cancer would be: “If you want to try clinical trials for a last ditch, I’ll see what I can enrol you in, but don’t go expecting miracles. From all we know, your cancer is incurable. Your job now is to get on and live the rest of your life as enjoyably as you can; mine is to cancel out as much suffering as I can while you do so. Come back as soon as things start getting difficult; my door will be open to you.”

  17. #17 epador
    November 22, 2006

    Now there’s a leap: Socialized Medicine as a Cure for Quackery.

    Kinda like the hair of the dog that bit you.

    But great post, and yes there are some places where the “informed consent” is tainted, but my experience is that patients and families are as least as likely to distort or misunderstand what they are told in the process filtered by their own desires and prejudices, as the investigators are to color the discussion less than objectively.

    And to add to Orac’s notes about surgical consults on bowel obrtuctions due to abdominal carcinomatosis: sometimes we med oncs make that consult because the family doesn’t or won’t believe us without hearing it from you, that there’s nothing else to do. And sometimes, we don’t want to make that call. So slap us up the side of the head with some Respectful Insolence, but be gentle.

  18. #18 SP
    November 23, 2006

    Clark Bartram said, “I am a life coach.”

    Then you must be a big red flag.

  19. #19 Joe
    November 23, 2006

    @SP- You wrote “The previous posts and the followers of this blog, don’t seem to point out any of the weaknesses of EBM and “conventional” medicine while burning CAM at the stake.”

    The drawbacks of medicine do not mitigate, in any way, the nonsense that is CAM. Pointing to problems with EBM is a topic-changing, tuo quoque fallacy in argument. EBM and CAM are separate topics.

    So, complain about EBM if you wish; but keep in mind that CAM fails on its own.

  20. #20 Orac
    November 23, 2006

    Wrong. Merely pointing out that there are three fingers pointing back at you when one is pointing at the other person. I am not writing a defense of CAM or opposing EBM. You have not read carefully if you can’t see that I am actually opposing all or none thinking. I’m merely proposing a more checks-and-balances style of thinking with which everything should be evaluated. The previous posts and the followers of this blog, don’t seem to point out any of the weaknesses of EBM and “conventional” medicine while burning CAM at the stake. I am merely providing the counterpoint.

    That’s just lame.

    I’m sorry, but there’s no other way to describe it. All you’re doing is regurgitating the same tu quoque fallacy and nonsequitur that I described in my post.

    Repeat again after me:

    Shortcomings in how well conventional physicians deal with end-of-life issues are IRRELEVANT to whether or not CAM “works” in cancer or does better dealing with end-of-life issues. Nor are such deficiencies valid arguments in favor of incorporating CAM into conventional medical practice. Joe is correct. The shortcomings of conventional medicine do not mitigate the nonsense of CAM or the quackery that is all too frequently represented as CAM.

    As for the “all-or-none” thinking, deny it all you want, but in the guise of bringing “nuanced” thinking to this issue you are in reality repeating an “all-or-none” canard. You seem to think that, if conventional medicine tells a patient that it can’t cure his cancer, then it is simply telling him to “go home and die.” In fact, there is a continuum of modalities ranging from primarily curative to pure palliation. Good oncologists know this and practice it every day.

  21. #21 James
    November 23, 2006

    It seems to me that this “science doesn’t explain everthing” argument should be classified as a fallacy in its own right. I mean it is a tu quoque and a non-sequitur, but it also seems to have an element of false dichotomy to it as well. basically saying that an idea is either perfect or it is just as good as every other imperfect system. Perhaps we should call it the “argument from false perfection” fallacy, what do you think?

  22. #22 Bronze Dog
    November 23, 2006

    It’s already got a name: It’s called the perfect solution fallacy.

    I’ve also got “Science doesn’t know everything!” covered in my own fashion.

  23. #23 HCN
    November 23, 2006

    SP: I interpreted Clark Bartram claim that he is a life coach to be that he is a parent.

  24. #24 Nes
    November 23, 2006

    James: Is it being Doggerel close enough?

  25. #25 SP
    November 23, 2006

    The shortcomings of “conventional” medicine do, however, warrant not standing on the “greater than thou” pedestal. I’m glad you guys, with all of your latin terms, are not running this country. Balance does not seem to thrive here.

  26. #26 James
    November 23, 2006

    I do not live in your country SP so it is highly unlikely I will ever end up running it.

    But you are still missing the point. If A is less than infinity and B is less than infinity, does that mean A = B? The answer is no. Two imperfect things are not equal simply because they are both imperfect. It is not unreasonable to point out the (numerous) shortcomings of alternative medicine notwithstanding the (far fewer) shortcomings of conventional medicine. And balance is irrelevant here. Balance is important only when considering things that are euqal or at least equivalent.

  27. #27 Andrew Dodds
    November 24, 2006

    SP –

    Actually, this whole idea of ‘balance’, where we are apparently not allowed to say that one idea is better than another just because it happens to be overwhelmingly supported by the actual, physical evidence is a major problem in politics and public discourse. We have people claiming that creationism and evolution are ‘in balance'; we have a tiny monority of global warming skeptics ‘balanced’ against the entire community of climatology.

    Indeed, this isn’t ‘balance’, it’s a childish refusal to admit to being wrong.

  28. #28 anonimouse
    November 24, 2006

    SP,

    Repeat after me.

    We are discussing CAM. We are not discussing EBM.

    All you are doing is obfuscating the real issue, which is the obvious shortcomings of “alternative” medicine, in favor of your anti-mainstream medicine agenda.

    You’re not half as good at it as you think you are, either. Believe me, years of seeing the mercury militia and the anti-vax nutjobs has made me keenly aware of how to put a thin veneer of objectivity over an absolutist position.

  29. #29 Dino
    March 22, 2008

    your a dick

  30. #30 Dino
    March 22, 2008

    your a dick

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