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April 29, 2007, Volume 14 Nr. 8, Issue 227 Alternative
Ethics So-called “alternative medicine” is not a field of health care, but a culture:
Another cultural aspect that identifies and coheres these practices is Alternative Ethics. The new age of “complementary and alternative medicine”, or CAM, was, in part a reaction to ethical problems coming to light in medicine in the last third of the 20th century. Legitimate concerns were raised about paternalism, lack of informed consent, abuse of power, experimental bias and sexism, to name a few. In the past few decades, medical ethics has advanced and leapfrogged ahead of the pretensions of CAM, but popular stereotypes about medicine persist and are exploited by promoters of CAM. CAM has long sought to use the language of science and medicine to boost pseudoscience, handily sidestepping demands for good evidence. There is one area where CAM has taken on the practices of medicine. Not modern medicine, however. Old-fashioned medical ethics are common to CAM, including paternalism, lack of informed consent, abuse of power, experimental bias and sexism. The skeptical and scientific blogworld is in a deep discussion about strategic appeasement over whether science and religion can play nice together. I am going to look at some of the ethical muck of appeasement that has dirtied health care. The appeasers are those who trumpet “integrative medicine”. Seeing themselves as moderates, a bridge between hostile camps of “allopathic” and “alternative”, the integrations are a muddy waffle that is dishonest at its core. Integrative medicine, combining the best of conventional medicine with the best of alternative therapies, sure sounds like a great idea. But its foundational assumptions are flawed and its implementation is naïve at best. While many CAMs are dangerous (despite the hype about how “gentle” and “supportive” CAM is), even practices that are harmless serve to legitimize the culture of CAM as a whole. Even benign CAM practices can be used unethically. In future pieces I will deal with other aspects of Alternative Ethics, but here I focus on conventional health care professionals acting as integrators of CAM. Those who (should) know better are the main promoters of “integrative medicine”. Scientifically trained, and by virtue of education and experience, doctors, nurses and dentists have significant authority and real power over patients. When a health care professional promotes nonsense such as homeopathy or Therapeutic Touch, his peers should call BS on the culprit. Those practices are disproved, as well as having no plausibility, but, amazingly, are among the more common quackeries practiced by integrators. Is it ethical to promote, as medical treatment, a practice that has no biological plausibility, which actually denies what we do know is real, such as basic physics and physiology? No, it is not ethical. A popular defense, “it won’t hurt anyone”, is thin. Non-harming is a robust ethical principal, but it is often meaningless or misused in CAM. Along with another common defense: “it utilizes the placebo effect”, surely the integrators are damning with very faint praise. Homeopathy and Therapeutic Touch (TT) are a waste of both the nurse’s and the patient’s time. The counterargument pleads that time itself is the key to why homeopathy and TT are valuable. The therapeutic relationship is important to compliance and to placebo, so the extra time it takes to provide pretend medicine is justified as developing the relationship. To assume we must fool our patients with ritual magic in order to gain their trust so they will follow a reality-based treatment plan is to dishonor both our patients and our professions. Since both TT and homeopathy are faith-based (vs. reality-based) practices, it can be argued that they are needlessly intrusive of the patient’s mental and physical space, as well as denigrating the patient’s autonomy and dignity. How insidiously intimidating for a patient – already made vulnerable by disease – to be coerced into CAM rituals by the very people who are supposed to be the patient’s advocates. Homeopaths engaged in the present debate in the UK (where prominent scientists and physicians decry the NHS money spent on pseudomedicine) are fond of arguing that even if homeopathy is only placebo, that is fine, since placebo means lots of folks feel better. Then they gloat that we cannot study homeopathy with randomized clinical trials. The argument is that to test homeopathy with double blind, placebo controlled, randomized clinical trials, a process that is certainly possible, would be inadequate to the task, since the therapeutic relationship is key. Well, of course it is, and it is fraught with biases no matter whether the therapist is an MD or a Reiki master. These biases can best be eliminated from the data by RCTs. Biases are not bad, by the way. Most health care workers have a bias against pain, for example. We are loaded with biases, and they are much of our charm, what make us human and wonderful. I am biased to think well of people, and one of the human accomplishments that I particularly admire is the scientific clinical trial, developed and refined to trump our biases. When a person consults with a health care professional, he is right to expect that that the professional will act according to the standards of her profession. If she promotes “alternative medicine” practices, then the patient may assume these are well tested, plausible and proven. Of course, they are none of these; if they were they would be medicine, no “alternative” about it. A new buzzword is “emerging medicine”. Watch out for it. There may be a legitimate way to call experimental areas of medical science “emerging medicine”, but it is such a convenient weasel word that CAM folks are using it willy-nilly. Anything, however implausible, that one can get someone to “research”, however poorly, is now “emerging medicine”. From the dangerous practice of chelating autistic children to the useless game of distant healing, there is dubious “medicine” emerging all over. “Popularity” is another common excuse health care workers use to defend their integration of quackery. Considering that the income of MDs in the US is flat or dropping, there is an attraction to CAMs. Most are directly paid for by the patient, not delayed reimbursement at set government or insurance schedules. Even better, CAMs require little or no training and most entail scant liability risk. Compare that with, for example, a surgeon learning new endoscopy procedures or a dentist learning new implant techniques. “Integrative medicine” is a cash cow for hospitals, and endowments are coaxing medical and nursing schools into a Faustian bargain as well. For a slice of your science-loving soul, you can join the CAM club. When your conscience nags you, try to drown it out with the chant: “The Emperor does so have clothes!” As health care workers, we should have a coherent set of ethics. These include applying the best science, continuing our education and refining our practice, and recognizing that knowledge is only valid if it is based in reality. As health care users, we should insist on such ethical care.
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Natural,
August 2006 |
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