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MJA Opposing views: Is it ethical to prescribe CAM that may lack an evidence base?

The MJA has posted two opposing views on this topic and MJAInsight has a commentary on the issue that you can view in the box below:
[box=Alternative medicine debate erupts, Sophie McNamara]A FIERCE debate has ignited over the ethics of prescribing alternative therapies that may lack an evidence base.

Writing in the “Opposing views” section of theMJA, Professor John Dwyer, emeritus professor of medicine at the University of NSW, said many alternative therapies are not based on science and it is unethical for doctors to prescribe them in most situations. (1)

Consumers were increasingly exposed to “a plethora of nonsense (non-science) claims that waste their money, distance them from effective care strategies and, not infrequently, cause harm”, he wrote.

Presenting the opposing view, Dr Marie Pirotta, of the department of general practice at the University of Melbourne, said patients wanted to receive information about complementary or alternative therapies from their GPs. (2)

“… it is important for GPs to discuss CAM [complementary and alternative medicine] options with patients to ethically fulfil their role as trusted primary care providers”, she said.

Professor Dwyer criticised doctors who practised “integrative medicine”, an approach which combines conventional medicine with complementary and alternative therapies.

“To do so … is to abandon scientific medicine … for an approach that does not believe in testing, is happy to exploit the placebo effect and rejects a psychological influence on health”, he wrote.

Professor Dwyer’s comments sparked a strong response from the Australasian Integrative Medicine Association (AIMA), the peak body for doctors practising integrative medicine.

AIMA president Professor Kerryn Phelps said Professor Dwyer’s comments “make my blood boil, because they are so ignorant and so offensive”.

“It is a professional insult to the highly intelligent, science-based doctors who are practising integrative medicine. It’s also a very narrow, parochial view. In the US, more than 60% of medical schools have an integrative philosophy”, she said.

Professor Phelps described integrative medicine as “the emerging mainstream”.

Previous MJA research has shown that more than half the Australian population uses complementary or alternative therapies each year, at a cost of more than $2 billion. (3)

Professor Phelps said given the number of people using these therapies, it was unethical for doctors not to practise in an integrative way.
“Doctors who don’t inform themselves in this area, which is impacting on their practice whether they know it or not, are not practising optimally and may well be putting themselves at [legal] risk”.
Dr Pirotta said ethically recommending any treatment took place within the framework of a careful history, examination and diagnosis.

“Discussions of CAM options (including recommending or discouraging use, as appropriate) can be ethically incorporated into this framework.”

Professor Dwyer said scientific study of alternative medicine was important, and that any treatment found to have supportive evidence should be embraced by orthodox medicine.

However, Dr Pirotta said that a lack of evidence did not mean that a treatment was ineffective or harmful.

“It is estimated that as little as a quarter of conventional medicine is based on level-1 evidence”, she wrote.

Dr Pirotta said the evidence base for complementary treatments was slowly growing, despite barriers such as the lack of financial reward for research investment.

Professor Phelps said evidence was a “moveable feast” and cited changing evidence for orthodox treatments such as cyclooxygenase-2 (COX-2) inhibitors and hormone replacement therapy.

“A lot of the pharmaceutical treatments that were supposedly evidence based have been discredited, negative studies are not published and so on. I think evidence itself is flawed.”

In acomment published in this issue of MJA InSight, Dr Sue Ieraci wonders why a sophisticated consumer market holds such belief in alternative medicines.

– Sophie McNamara

1. MJA 2011; 11 July (online)
2. MJA 2011; 11 July (online)
3. MJA 2004; 180; 587-589

Posted 11 July 2011

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My opinion on the issue it is usually not ethical, especially where studies showing no effect exist (e.g. acupuncture), because it is an abuse of the role of the doctor. Providing evidence based treatment is a huge part of what modern medicine is and its what separates doctors (and their government funding) from quacks. Doctors should hold on tight to the principles of EBM for the sake of their professional identity.
    <blockquote>My opinion on the issue it is usually not ethical, especially where studies showing no effect exist (e.g. acupuncture), because it is an abuse of the role of the doctor. Providing evidence based treatment is a huge part of what modern medicine is and its what separates doctors (and their government funding) from quacks. Doctors should hold on tight to the principles of EBM for the sake of their professional identity.</blockquote><br />
    <br />
    I agree. EBM is what defines modern medicine.
      <blockquote>I agree. EBM is what defines modern medicine.</blockquote><br />
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      Agreed. We had a debate on this in one of our PPD groups and I was surprised at the number of students who jumped ship and said that they would recommend alternative therapies.
    An interesting topic that I was actually talking with my parents about last night... I agree that doctor's shouldn't be recommending treatment that isn't supported by evidence, but I don't feel that alternative medicine should be thrown out all together. Specifically, I've seen a number of GP's tell their patients (some of whom being my family members) that the alternative medicine - acupuncture, chiropractor, etc etc. - they're pursuing is completely worthless and is just wasting their money. Now sure, on an evidence based medicine level this may seem true, but when I see the effect that it has on my family members and myself personally I can't bring myself to agree. I'm of the opinion that doctor's should do their best to help the patient in any way they can, be that prescribing medicine, giving a treatment plan, counselling.. and if a patient says "____ has really been making me feel better" the last thing that a doctor should say -<span style="font-weight:bold;">provided ____ has no negative health repercussions</span> - is "that's absolute crap, it doesn't do anything, stop doing it."<br />
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    <br />
    There are circumstances, of course, where I would change my mind - e.g. if the treatment they're pursuing is relatively too expensive for their income and so forth - but ultimately I feel that if it's helping the patient then I would be doing my job.
      <blockquote>An interesting topic that I was actually talking with my parents about last night... I agree that doctor's shouldn't be recommending treatment that isn't supported by evidence, but I don't feel that alternative medicine should be thrown out all together. Specifically, I've seen a number of GP's tell their patients (some of whom being my family members) that the alternative medicine - acupuncture, chiropractor, etc etc. - they're pursuing is completely worthless and is just wasting their money. Now sure, on an evidence based medicine level this may seem true, but when I see the effect that it has on my family members and myself personally I can't bring myself to agree. I'm of the opinion that doctor's should do their best to help the patient in any way they can, be that prescribing medicine, giving a treatment plan, counselling.. and if a patient says "____ has really been making me feel better" the last thing that a doctor should say -<span style="font-weight:bold;"> provided ____ has no negative health repercussions</span> - is "that's absolute crap, it doesn't do anything, stop doing it."<br />
      <br />
      <br />
      There are circumstances, of course, where I would change my mind - e.g. if the treatment they're pursuing is relatively too expensive for their income and so forth - but ultimately I feel that if it's helping the patient then I would be doing my job.</blockquote><br />
      <br />
      <blockquote>An interesting topic that I was actually talking with my parents about last night... I agree that doctor's shouldn't be recommending treatment that isn't supported by evidence, but I don't feel that alternative medicine should be thrown out all together. Specifically, I've seen a number of GP's tell their patients (some of whom being my family members) that the alternative medicine - acupuncture, chiropractor, etc etc. - they're pursuing is completely worthless and is just wasting their money. Now sure, on an evidence based medicine level this may seem true, but when I see the effect that it has on my family members and myself personally I can't bring myself to agree. I'm of the opinion that doctor's should do their best to help the patient in any way they can, be that prescribing medicine, giving a treatment plan, counselling.. and if a patient says "____ has really been making me feel better" the last thing that a doctor should say -<span style="font-weight:bold;"> provided ____ has no negative health repercussions</span> - is "that's absolute crap, it doesn't do anything, stop doing it."<br />
      <br />
      <br />
      There are circumstances, of course, where I would change my mind - e.g. if the treatment they're pursuing is relatively too expensive for their income and so forth - but ultimately I feel that if it's helping the patient then I would be doing my job.</blockquote><br />
      <br />
      Well what other alternatives are there to not telling the truth? BSing and saying "CAM can be beneficial to the patient" when you're entire professional opinion is completely the opposite? I'd rather have a doctor tell me what their professional opinion is (i.e. the thing I am paying them for) rather than make value judgements on my income and wealth and then give me a BS false opinion to butter me/shut me up. I'd rather the doctor tell me that my chiropractorial therapies work based on placebo effects (or whatever the consensus is) rather than endorsing non-evidence based CAMs (especially when its against the orthodox health opinion). <br />
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      If doctors start BSing and endorsing such therapies to not hurt the feelings of patients on these treatments, ten these patients would be more likely to recommend these therapies to their family members and friends. Although CAMs can make YOU (specifically) feel better, the reason they do not have a strong line of evidence backing up their use is they don't show evidence of improving EVERYONEs (generally) health outcomes (otherwise they would've been endorsed by the medical orthodoxy). Although it may work for you, it may not work for your friends and since your GP endorses the treatment whilst your friends GP is giving him/her their real opinion on CAMs, it'll just confuse both of you guys and lead to misinformation amongst the general public on where medical practitioners stand on these therapies. It may also lead to GP distrust (I know I wouldn't trust a GP recommending sugar pills to me to shut me up instead of engaging in discussion and giving their professional opinion).
        <blockquote>Well what other alternatives are there to not telling the truth? BSing and saying "CAM can be beneficial to the patient" when you're entire professional opinion is completely the opposite? I'd rather have a doctor tell me what their professional opinion is (i.e. the thing I am paying them for) rather than make value judgements on my income and wealth and then give me a BS false opinion to butter me/shut me up.</blockquote><br />
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        This is definitely not what I meant. My point was more focused around the idea that if a patient is suffering from something (say, for example, chronic back pain) and you have so far been unable to treat them efficiently/effectively and they come to you saying "my chiropractor has really helped with the pain" then there's no way in hell I'd say "stop going, it's useless" because it clearly isn't. I would give them the EBM opinion that it makes little/no difference but if they feel it's helping them and I can't see that it's impacting them negatively in any real way then I'm certainly not going to tell them to give up on the one thing that's worked for them. I'd still try to find an EBM treatment plan to treat the cause rather than the symptoms, but in the meantime if they've found something that relieves their symptoms I'm not going to cut them off it. <br />
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        In clearer words, my point is that if a patient came to me with some kind of chronic condition and said "I've been taking these pills and they've been really helping" and I knew they were sugar pills or vitamin C tablets or whatever I'd tell them straight up that it probably isn't doing anything realistically, but I wouldn't tell them to stop it if it's helping them. I don't feel this is endorsing alternative therapies as much as it is supporting the patients autonomy in their treatment decisions.
          Well in that case you are not practising EBM, even if you toe the party line and say that it is probably doing nothing. Simple anecdotal evidence for a particular treatment's efficacy is not enough for you as a practitioner of Western medicine to recommend it. This is especially true when the CAM they are receiving has the potential for harm - chiropractic carries with it a greater chance of harm than therapeutic benefit. You should always look at risk vs benefit for any treatment. A 2007 review into chiropractic found that the therapeutic benefit is uncertain but the risk of harm is definite, albeit small. Why on earth would you recommend something like that? On the other hand, if the patient reports that draping themselves in lavender and chanting an ancient hymn makes them feel better - meh, that may not help with anything but the risk is negligible as well. In my opinion it's simply not ethical to recommend any CAM that carries with it a risk of harm, when it has no proven therapeutic benefit either. If it did have a proven therapeutic benefit it wouldn't be a CAM - it'd be medicine.
          <blockquote>This is definitely not what I meant. My point was more focused around the idea that if a patient is suffering from something (say, for example, chronic back pain) and you have so far been unable to treat them efficiently/effectively and they come to you saying "my chiropractor has really helped with the pain" then there's no way in hell I'd say "stop going, it's useless" because it clearly isn't. I would give them the EBM opinion that it makes little/no difference but if they feel it's helping them and I can't see that it's impacting them negatively in any real way then I'm certainly not going to tell them to give up on the one thing that's worked for them. I'd still try to find an EBM treatment plan to treat the cause rather than the symptoms, but in the meantime if they've found something that relieves their symptoms I'm not going to cut them off it. <br />
          <br />
          In clearer words, my point is that if a patient came to me with some kind of chronic condition and said "I've been taking these pills and they've been really helping" and I knew they were sugar pills or vitamin C tablets or whatever I'd tell them straight up that it probably isn't doing anything realistically, but I wouldn't tell them to stop it if it's helping them. I don't feel this is endorsing alternative therapies as much as it is supporting the patients autonomy in their treatment decisions.</blockquote><br />
          <br />
          Interesting point, although, it sounds to me like you're against the prescription of CAM just not keen on shooting it down in flames.
          <blockquote>Interesting point, although, it sounds to me like you're against the prescription of CAM just not keen on shooting it down in flames.</blockquote><br />
          <br />
          Essentially.. I wouldn't prescribe it because it hasn't been shown to be beneficial for everyone/majority of people, but if a patient came to me saying that they felt it was helping them (especially if I was at a loss with how to treat them - see many, many chronic back pain cases) then I wouldn't tell them to stop going.. On the topic of chiropractic care being potentially harmful I pose this: if you were getting the same effect from chiropractic care as you were from painkillers, which would you use or recommend?
          <blockquote>Essentially.. I wouldn't prescribe it because it hasn't been shown to be beneficial for everyone/majority of people, but if a patient came to me saying that they felt it was helping them (especially if I was at a loss with how to treat them - see many, many chronic back pain cases) then I wouldn't tell them to stop going.. On the topic of chiropractic care being potentially harmful I pose this: if you were getting the same effect from chiropractic care as you were from painkillers, which would you use or recommend?</blockquote><br />
          <br />
          I wouldn't necessarily tell them to stop going either. Although, I've seen many patients who use CAM to enter the 'sick role' (not sure if you've been taught that concept yet) and I think CAM often interferes with the pursuit of evidence based treatment that mightn't be as free from side effects as CAM or as externally validating.
Worth a read.<br />
<a href="http://www.mjainsight.com.au/view?post=jane-mccredie-law-shuts-down-criticisms&post_id=5037"><br />
http://www.mjainsight.com.au/view?post=jane-mccredie-law-shuts-down-criticisms&post_id=5037<br />
</a><br />
<blockquote>The threat of legal action was often used to stifle scientific debate and prevent responsible investigative journalism, the <span style="font-style:italic;">BMJ</span> said. That’s something public health physician Dr Ken Harvey could relate to.Harvey has been a long-time campaigner — including in his recent <a href="http://www.mjainsight.com.au/view?post=ken-harvey-diet-pills-need-weightier-regulation&post_id=4533&cat=comment">article</a> in <span style="font-style:italic;">MJA InSight</span> — for more stringent regulation of the alternative medicine industry in this country, and he has copped a lawsuit for his pains.<br />
<br />
After he complained to the Therapeutic Goods Administration about the weight-loss product SensaSlim, Harvey found himself facing a reported $800 000 defamation suit initiated by the product’s manufacturer. Among claims made for the product are that data from “the world’s largest weight loss trial” show a staggering 87.2% of subjects lost 10% or more of their body weight. And that was without any instructions to modify their diet or exercise habits.</blockquote>
    Nice article, L8. This is the most worrying part about it, I think:<br />
    <br />
    <blockquote>Not only can experts be muzzled by defamation cases, but government <a href="http://www.austlii.edu.au/au/legis/cth/consol_reg/tgr1990300/s42zcaj.html">regulation</a> in this country forbids the TGA from investigating a complaint about a product while legal proceedings are underway.<br />
    <br />
    So, the message for any company facing criticism in the future is clear. If there’s a complaint to the TGA about one of your products, sue the complainant and you can shut the whole thing down quick smart.</blockquote><br />
    <br />
    Defamation lawsuits seem to make it very difficult for anyone to challenge these companies claims..
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