We've talked quite a bit about ethics in this space, especially medical ethics and "blog ethics". Today, though, we will specifically 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.
Who is a physician?
The identity of "physician" in North America is generally understood as referring to someone who has completed medical school, other requisite training, and is practicing medicine. In other cultures, there are other types of healers (such as curanderos) and how our ethics may apply to them is unclear.
What about people who present themselves as doctors, but do not practice the science-based medicine that we teach and practice? They may have an M.D. or D.O. degree, they may even be board-certified, but if they are practicing outside of the standard of care, are they still bound by the same system of ethics as their more traditional colleagues?
Absolutely. Anyone who presents themselves as a doctor must behave in a way concordant with medical ethics. A patient seeking help should expect the same ethical treatment from all practitioners. No doctor is exempt from our ethical principles.
What about a doctor who believes in the implausible medical claims that they practice? Since they believe that they are helping the patient, aren't they behaving ethically?
If intention were the only principle of medical ethics, well, sure. But good intentions do not excuse incompetence, and one of our responsibilities as physicians is to strive for excellence in our knowledge and practice. This means maintaining our science-based education.
What about non-physicians who offer quasi-medical services? Professionals such as nurse practitioners have their own codes of ethics, but often enough non-professionals such as homeopaths, acupuncturists, and others present themselves as healers. Patients have a responsibility to educate themselves and protect themselves from harm, but people who are suffering are vulnerable, and these modern shamans take advantage of this vulnerability. While they are not bound by the same medical ethics that I am, they are bound by the same ethical principles that all of us are as members of a larger society. As a society, we generally frown upon folks pretending to be experts and futzing around with people's health and hopes. We only tolerate "alternative healers" because their deceptions extend beyond their victims---we sometimes believe they are doing good, even if they are not.
Alternative medicine is prima facie unethical
To the extent that alternative practitioners are bound by medical ethics, alternative medicine is unethical. It violates most of the commonly agreed-upon precepts of our profession. Medicine is based on the humane application of science-based practices. Standards of care are based on either what has been shown to work, or when insufficient data is available, what we as a profession agree is likely to work. There are written resources that any doctor can look up in minutes. Cult medicine practitioners don't "slip" away from real medicine, they intentionally turn away from it, sometimes with good intentions, sometimes not. So-called alternative medicine practices are ethical failures on many levels. As to the principle of beneficence, the most benefit they may offer is emotional comfort, something real medicine could just as easily offer. When it comes to non-maleficence, it fails miserably, in that it often deprives patients of real treatments, or subjects them to ineffective ones.
When it comes to patient autonomy and truthfulness, however, it really hits a wall. For a patient to exercise autonomy, they must be as informed as possible. If an altmed practitioner were to truthfully inform patients that the wares they are peddling have never been shown to be useful, are shunned by real doctors, and may in fact harm, patients would knock each other down to get out the door. But they don't. When they do give lip service to the unproven nature of their practices, it is always with a wink and a spiteful nod to those silly non-believers at the hospital.
Even the most heartfelt modern shaman is an unethical sham. Alternative medicine, that is medicine that is outside the embrace of science-based practice, is inherently unethical, and it's time to call it what it is---a blight on our profession, and so far as we tolerate it, a blight on us all.
The American Medical Association's Principles of Medical Ethics
- Log in to post comments
To preempt the inevitable "altie" attack: that's as a "guild." We're talking about human beings, not deities, so of course individuals have not always lived up to the expectations set for them, nor have groups overseeing medical ethics always demanded the compliance with complete rigor.
If you don't like it, take your issues up with the representatives of your favorite $DIETY. Televangelists, for instance, or Catholic priests.
Nice post, PAL. I have been absolutely staggered by the fact that even the most respected medical schools have succumbed to "market pressure" and offered some kind of "training" altmed, instead of robustly debunking it.
PP, are you feeling all right?
Pal, who are you to be an authority on what is real and what is "alternative". Isn't this just your arbitrary objection to another kind of medicine that a lot of people would disagree with? Who are you to decide what they do is unethical if they think it works?
/end CPP POMO drivel
Sheesh, you give a scathing review of "alternative medicine" without first even defining what you mean by "alternative medicine".
Here're my two bits:
Most people who use "alternative medicine" also use allopathic medicine. For example, a chemotherapy patient using Reiki or acupuncture to help overcome the side effects of nausea and fatigue - is it somehow unethical for her/him to receive such treatment, is s/he misinformed? If he/she continues to voluntarily pay for these services and feels they are beneficial, is s/he deluded and needs to be smacked in the face with a blinded study?
If you're putting up the argument that allopathic medicine practices are always based on hard evidence. If so, then every MD who orders a TSH on an asymptomatic female patient with prior hx, or a PSA on an asymptomatic male patient with no prior hx, or prescribes a Zpack for "bronchitis" should be thoroughly upbraided, fined and then stripped of their medical licenses cause these practices definitely are NOT supported by any studies.
Your post is dripping with disgust at alternative medicine; but please realize that allopathic medicine and alternative medicine can both treat patients, they just treat different aspects of their wellbeing. If a alternative practioner claims to cure cancer with a herb potion, then s/he should be barred from practice forever, but please do not tell me that there are never any crooked MD's who implant pacemakers because medicare pays for it (personally saw a patient in this situation), or prescribes un-unecessary tests and procedures simply because they care more the bottom line...
There are crooked practioners of all kinds of medicine. I could throw out all of allopathic medicine based on the bad practices of a few, but that would be unfair and plain stupid. The same goes for discounting all alternative medicines based on your biases.
Another troll who can't be bothered to read. "Alternative" medicine that is shown to work reliably is no longer "alternative". Reiki, acupuncture, chiropractic, etc. have all been shown to be useless. Repeatedly. Placebo effect aside, all these people are paying for is for someone to be nice and listen to them. A nice idea, but not medicine.
Another thing I have noticed; whenever someone uses the term "allopathic" to refer to science-based medicine, you can bet that they are a crank. Quoting the father of woo, Samuel Hahnemann, is not generally a sign of a healthy mind. Just sayin'!
There are cases of mutual respect between physicians and other practitioners such as acupuncturists, where they refer patients to each other. Isn't a spirit of cooperation like this in the best interest of the patient and therefore ethical practice.
-----------------
As to the principle of beneficence, the most benefit they may offer is emotional comfort, something real medicine could just as easily offer.
------------------
So all in all real medicine has only advantages.
Now the question: Why do people choose alternative medicine at all ?
Stupidity is not an explanation because even stupid people will sooner or later visit a practice or a hospital so doctors are able to convince them of their advantages. Eccentrics (like the ones who still prefer the typewriter instead of a computer) are not an option either because there are too many adherents and the practice of alternative medicine is too widespread.
So why ?
The fact that it is done not render it ethical.
For many of the same reasons that they choose a doctor, a barber, or a manicurist. Once again, argumentum ad populum is not a convincing argument for good ethics (although it's not immediately invalid...)
Pal, interesting and spirited post. I am not commenting on whether alternative medicine is ethical or not, but rather on your comment that "ethics are not static." I agree with your assessment that society increasingly emphasizes respect for patient autonomy, replacing the more paternalistic medicine of former decades. However, I don�t think this is because our ethics as a whole has CHANGED but rather that the APPLICATION has refined.
Respect for autonomy is a fundamental and dare I say universal ethical principle � it is the application that evolves. Perhaps the patients in the past favored a more paternalistic medicine- therefore not to act as such would not have fully honored the wishes of the patient (ie their autonomy). Whereas now patients prefer to have more information and to make their own decisions (some say a portion of this stems from a break down in the doctor-patient relationship - a breakdown in mutual trust).
As a bioethicist in NY(www.bioethicsinternational.org), I don�t think we can say that previously clinicians had no responsibility to respect patient's freedom, now suddenly it is the right thing to do, and tomorrow maybe it won�t be. I think the apparent change is a change in application, not foundation. It would be interesting to hear others� thoughts.
In my experience, most usually choose alternative medicine because of one simple thing: hope. Most try it on the basis that it can't hurt to try, and hey, what if it turns out to work? This can range from relatively simple things, like shortening the duration of a typical cold, to things like chronic pain, to really serious stuff like terminal cancer. Obviously, it *can* hurt to try, for a variety of reasons, but hope is a powerful motivator, and it can make the cost seem much less dear than it really is.
One other reason I can imagine some people would pick quackery: The alties have done everything they can to foster an image as rebels against corporations, governments, and us squares who obviously wear lab coats every day and don't get abstract art.
Some people like to think they're sticking it to the man by siding with the free spirits who love to employ censorship when criticized.
The best practical definition I've seen of complementary and alternative medicine (CAM) is Steven Piantadosi's, from Clinical Trials, a Methodological Perspective:
It doesn't get any shorter, nor sweeter, than that.
If physicians cannot provide a satisfactory solution then surely patients are justified in considering alternative therapies. They could wait and hope the condition improves or accept the negative prognosis. Are there any other options?
Don C. said "Are there any other options?'
It is called death or pain without relief.
For examples Google "Tariq Nadama" or check out these photos outside of the clinic from a woman who wrote a book titles "Cure for All Diseases":
http://www.ratbags.com/rsoles/comment/clark08.htm
> For many of the same reasons that they choose a doctor, a > barber, or a manicurist.
That's a foggy answer. Besides, I didn't state that choosing alternative medicine says anything about their effectiveness. I am confronting you with your conclusion that real medicine has only advantages by asking you why anyone chooses alternative medicine.
We know that several professions (like scissors grinder) are extinct now because buying new scissors are cheaper than grinding them. Noone can sell flint and steel as main job compared to lighters or matches. While there are dentists offering alternative medicine, there are curiously neglible alternatives to dentists.
> In my experience, most usually choose alternative
> medicine because of one simple thing: hope
Well remarked. Which begs the question: Why don't the real medicine offer hope ? Why put people equal or less trust in real medicine (else it would be easy to lure them away if they perceive the healers as quacks) ? While in case of terminal illness you can argue that you must tell the truth and cannot offer hope, you also lose your argument of superior quality: The result of both alternative and real medicine is equally unpleasant in this case.
I would like to hear PalMD's explanation first before commenting.
I don't think alternative medicine patients accept the idea that alternative medicine only gives comfort and placebo. They have used doctors and used alternative practicioners, and the alternative people sometimes help where doctors don't. To rail about this sounds like sour grapes.
The so called gold standard of medical studies is way overrated. It is expensive, cumbersome, and almost systematically corrupted by drug company funding of studies, and the suppression of "negative" results. (And, if this site dedicated to attacking alterntive medicine is not funded by drug companies, there are many similar sites which are.) Limiting scientific medicine to "gold standard" studies is not real science, but formalistic science, rather like mandarin examinations in ancient China. Both gold standard studies and mandarin examinations show knowledge, but whether they show the most sensible knowledge or treatment is questionable.
Clinical observation and clinical studies should be given more weight, and here alternative medicine has many evidence based treatments.
I can haz evidence, pleeze?
There are *no* evidence based *anything* in alternative medicine. If there were, it would not *be* alternative.
Oh great, another straight MD who is terrified that they really don't know jack about how to "first do no harm".
Ethically-practiced medicine offers hope when there are confirmed, well-established and rigorously-tested therapies that offer good chances of recovery.
Where the treatment has low chances of recovery or survival, conventional medicine cannot offer much hope. It must, however, offer honesty. Ethical doctors should not offer false hope.
CAM, with a frequent basis in crank science and with only the poorest-quality evidence as support (and tons of evidence showing no efficacy), offers false hope. Any time some altie quack promises to "cure cancer" (see HCN's link above), charging tens of thousands in the process, they are offering false hope.
People believe what they want to believe. A dying person will be even more prone to trying things that 'might' prolong survival. That CAM offers "hope" in situations where evidence-based medicine has not yet found a cure, says nothing about the validity of CAM's claims.
Minimalist had the termerity and audacity to assert:
"Ethically-practiced medicine offers hope when there are confirmed, well-established and rigorously-tested therapies that offer good chances of recovery."
A good part of standard medicine is based on experience, the skill of the MD and clinical practice as well as research. Seen any double blinded placebo controlled tests for heart surgeries, knee replacements or chemotherapy lately?
Minimalist continues:
"CAM, with a frequent basis in crank science and with only the poorest-quality evidence as support (and tons of evidence showing no efficacy), offers false hope."
What??!!
This continued assertion that much of CAM research ("frequent basis in crank science") is nonsense, quack and crank science is really an INSULT to the dedicated
researchers out there, many of them MD', PhD's, chemists, physicists. Try telling Dr. I. Bell MD, PhD, prominent Homeopathy researcher that her work is nonsense.
Try telling M. Ennis, pharmaceutical researcher that her research concerning the stimulation of biological activity by basophil cells by a substance diluted past the Avogadro limit, and the subsequent publication of her results in the Journal Inflammation Research was crank science.
Also tell it to the recent researchers who CONFIRMED it in these
citations:
1: Lorenz I, Schneider EM, Stolz P, Brack A, Strube J.
Influence of the diluent on the effect of highly diluted histamine on basophil
activation.
Homeopathy. 2003 Jan;92(1):11-8.
PMID: 12587990 [PubMed - indexed for MEDLINE]
2: Sainte-Laudy J, Belon P.
Use of four different flow cytometric protocols for the analysis of human
basophil activation. Application to the study of the biological activity of high
dilutions of histamine.
Inflamm Res. 2006 Apr;55 Suppl 1:S23-4. No abstract available.
PMID: 16705375 [PubMed - indexed for MEDLINE]
3: Sainte-Laudy J, Boujenaini N, Belon P.
Confirmation of biological effects of high dilutions. Effects of submolecular
concentrations of histamine and 1-, 3- and 4-methylhistamines on human basophil
activation.
Inflamm Res. 2008;57 Suppl 1:S27-8. No abstract available.
PMID: 18345504 [PubMed - indexed for MEDLINE]
4: Sainte-Laudy J, Belon P.
Improvement of flow cytometric analysis of basophil activation inhibition by high
histamine dilutions. A novel basophil specific marker: CD 203c.
Homeopathy. 2006 Jan;95(1):3-8.
PMID: 16399248 [PubMed - indexed for MEDLINE]
Oh there's junk research, shoddy research and crank reearch out there all right, just check through the "research" supportive of the tobbacco industry claim that smoking was not a causative factor in cancer and you'll find plenty of it, and some in CAM too, just like everywhere else - that does not make CAM nonsense.
Thanks, I will.
Okey dokey.
Gladly!
Here we go:
Homeopathy is bunk, peddled by idiots and fools with no grasp of scientific procedure. That some of them occasionally manage to publish their two-page, one-dimensional crank pamphlets in supplements to real journals* (that is, ones not named after the crank science being promulgated) is primarily a testament to one 'weakness' of peer review, which is to trust that the data being published is not the fabrication of a desperate soul or the product of an experiment incompetently performed by a feeble mind. But we can't demand replicability prior to publication, so what are you gonna do.
* The articles in Inflammation Research were summaries of research presented at the society's annual meeting, and not formal publications; as such, they were not rigorously peer-reviewed.
There are lots of professional creationists with reputable PhDs, too, which doesn't make creationism any less crap than it currently is. Those dweebs also try sneaky ways of publishing things that sound reputable (even going so far as to start their own crank journals), but are generally full of lose.
There's not much difference between a homeopathist and a creationist -- they're both peddlars of atavistic debunked philosophies designed to make the believers feel special. There's not much difference between your homeopathist telling you that you need a personalised prescription because allopathic medicine is too generic to handle each individual's case and a creationist telling you that you're far too unique and wonderful not to have been the personal project of a loving and involved deity...
No, they are not.
When my time comes (no hurry, mind) it will ideally find me with reasonable palliative care, my family nearby, and the windows open to the view over the Rio Grande valley.
That sure beats spending your last months in pain from denial of pain control and your "healer" telling you that it's all just part of the healing process, or that any problems are because you aren't complying with the program [1].
Thanks, I know where I'm headed eventually and prefer the truth.
[1] Look up the Gonzalez protocol for the whole ugly story.
Howdy, CJ. Nice try to keep the screaming caps under control.
I'll ignore the silliness of "double blinded placebo controlled tests for ... surgeries" for obvious reasons. As for chemotherapies, the simple answer is "lots and lots of them."
Of course, if you want to have a go at designing a way to blind-test surgery, go for it. If you can pull it off, you'll be in line for some serious prizes in medicine.
Meanwhile, we'll have to get by with case-controlled studies like the one that recently showed that arthroscopic treatment of tears to the tibial meniscus doesn't improve outcomes.
> When my time comes (no hurry, mind) it will ideally find
> me with reasonable palliative care, my family nearby, and
> the windows open to the view over the Rio Grande valley.
Just one side remark: "You" and "ideally". But many people don't have the money to pay for care. And if you mention "palliative care" it means almost always sooner or later morphine and other opioids. You know the problems physicians are facing in the US with the DEA ?
It is not so wonderful in the real world with the real medicine as it should be in your imagination.
> That sure beats spending your last months in pain from
> denial of pain control and your "healer" telling you
> that it's all just part of the healing process, or that
> any problems are because you aren't complying with the
> program [1].
And why on earth *does* the patient comply spending months in pain ?! The patient isn't incarcerated or chained to the wall. Nor is he isolated from doctors, friends or family. So the doctors have the *possibility to influence* the patient, but the patient decides *on his own free will* to stick with the healer !
Isn't that...hm....strange ?
> Any time some altie quack promises to "cure cancer" (see
> HCN's link above), charging tens of thousands in the
> process, they are offering false hope.
I don't know if you are doctor, but let's assume you are one. You are convinced that you have the better education, are smarter, have the better arguments and much more efficient medicine. And *still* some people ignore you.
How do you deal with this cognitive dissonance ?
> People believe what they want to believe.
You didn't say "alties" or "skeptics", but "people". Attention: I am now arguing what follows if the conclusion is true, not about reality.
If the conclusion is true, this whole site is totally useless because no amount of contradictory evidence will ever convince an altie because it clashes with his/her worldview (The other way round, too). Then this is only a place to vent off some steam of frustation and indignation.
Concerning the research into the effect of extremely diluted histamine on basophil activation. Lets assume for the sake of argument that these researchers have discovered a real phenomenon.
Histamine in normal concentrations activates basophils. If extremely diluted histamine still activates basophils, these researchers have disproved the basic principle of homeopathy "like cures like". Surely homeopathy would predict that histamine in extreme dilutions should suppress basophils?
A good practitioner should offer an honest assessment and only offer treatments that have at least plausible benefit. The practitioner should understand risks and benefits. This should be done with compassion, but without false hope. People get discouraged when their evidence based doctor doesn't seem to have much to offer. Then they persue other avenues. They want to hear that someone can make them better. This may give hope, but consumer beware. False hope can lead to harm.
If you all are wondering why so many people seek alternative treatments, perhaps the medical profession might consider changing how it publicly criticizes the pharmaceutical industry.
The more you diminish the perception of the drug industry, the more you diminish your own stature in the public eye. For after all, the patient comes to your door expecting to receive a magic bullet. And you docs seldom disappoint.
When you agree with your patients that the drugs are way too expensive, or portray well constructed and blinded studies as being useless because they were conducted using drug company money YOU are helping to drive your patients to charlatans.
For many of your patients, the only therapy that they will actually comply with is that pill. And you are the pill.
Penis enlargement pills are safe way to enlarge penis size. Penis enhancement pills have always been sold as novelty items for some time. How they managed to make their way into the mainstream is beyond my understanding. It is true that these pills may increase a manâs sex drive, they tend to contain a combination of herbs with aphrodisiac properties
Apparently, the answer is yes. At least as far as spammers go...
It's really great to post my comments on such a blog. I would like to appreciate the great work done by the web master and would like to tell everyone that they should post their interesting comments and should make this blog interesting. Once again I would like to say keep it up to blog owner!!!! http://www.naturalherbalsinc.com