Ethics of exclusively suppletive "alternative" medicine [Archive]

Rolfe

26th January 2009, 02:18 AM

There is already a word for what you're talking about. It's called "complementary medicine". It's the "C" is SCAM. (Supplementary, Complementary and Alternative Medicine.) In this case the "supplementary" is actually referring to the woo-woo promotion of spurious dietary "supplements". "Complementary" is the term for woo-woo techniques applied as an add-on to conventional treatment.

Some doctors are broadly in favour of this stuff because of the potential psychological benefits to the patient, as you point out. Some of the techniques are quite time-consuming, and they involve a lot of patient contact with the "therapist". This tends to be a positive thing in chronically ill patients where stress and anxiety are often significant contributors to decreased well-being. Many cancer centres include things like this for exactly that reason.

However, it's the element of lying which often creeps in that is so pernicious. It's one thing to provide hypnotherapy and massage therapy as aids to relaxation. It's quite another to provide complementary therapies with the explicit or implicit claim that there is actual medical benefit involved. What can happen is that the therapy is provided in good faith as a combination of relaxation and occupational therapy, but the therapist herself (they're usually female) is convinced that her method can actually influence the disease process and says so; so patients are misled with false hopes.

Or do you really think that misleading seriously ill patients with false hope is a good thing?

Then there is the additional problem that using alternative therapies in this way tends to legitimise them in the eyes of the public. So, a reflexologist and reiki practitioner (for example) who has nothing at all to do with this complementary use of the method, will then tout for business by claiming endorsement from the medical profession.

Hairdressing works just as well and involves no lying to the patient, as Soapy Sam is fond of pointing out.

A final problem with these techniques is that they are often portrayed as some sort of "self-help" therapy. Essentially the therapist is telling the patient that he or she can take control of the disease and influence it for the better by working hard at some exercise or other. Often this takes the form of developing a "positive attitude", and the inference is that those who can achieve this positive mind-set have a better chance of recovery.

No doubt it's better to be ill and cheerful than to be ill and miserable, but not everybody can manage this. And they don't have to and they shouldn't be led to believe they have to. They shouldn't be led to believe that if they are feeling miserable and can't shake that off, that this is actually decreasing their chances of survival. Most importantly, if things do take a turn for the worse, they should not be led to believe that this is their own fault, and that if only they'd worked harder on that positive attitude they wouldn't have suffered the relapse or the recurrence. And yet these are the negative down-sides of a lot of these up-beat "take control of your illness" complementary methods.

It's not nearly as clear-cut or no-lose as you seem to think it is.

Rolfe.

Blue Wode

26th January 2009, 03:11 AM

The one ethical problem I can see with it is that, because it feels better than the "real" stuff, people may overattribute their recovery to it, and thus be tempted to abandon the evidence-backed medicine, to their medical detriment. This is at least partially allayed by exclusively providing this treatment in the context of evidence-backed better-than-placebo care.

Your opinion?

You might be interested in Ernst’s opinion:
…we don't need placebos to generate placebo effects. This may sound paradoxical but, actually, is quite simple. The placebo-effect is a bonus that comes ‘free' (so to speak) with any treatment regardless whether it also has specific effects or not. It is therefore neither logical nor appropriate to use pure placebos that only rely on placebo effects – one might as well use treatments that have both specific effects and placebo-effects. In this way one makes optimal use of the “free bonus”.

-snip-

What seems important for maximising placebo effects is to administer treatments with empathy, sympathy, conviction etc – “the doctor who fails to have a placebo effect on his patients should become a pathologist”. A good therapeutic relationship may not be the only precondition for generating a sizable placebo response but it certainly helps.

Complementary practitioners often seem to be particularly skilled at building up strong therapeutic relationships with their patients. They certainly have more time but perhaps also more empathy and intuition. On the one hand, this is good news. It might enable them to be successful and have satisfied customers. On the other hand, there may also be a downside to it. Writing in The Guardian, Ben Goldacre explains: “Whether mainstream medics would want to go back to the old ways and embrace the placebo-maximising wiles of the alternative therapists is an easy question: no thanks. The didactic, paternalistic, authoritative, mystifying mantle has passed to the alternative therapist, and to wear it requires one thing most doctors are uncomfortable with, dishonesty”.

http://www.arc.org.uk/news/arthritistoday/131_1.asp

MRC_Hans

26th January 2009, 03:22 AM

I was about to write a long answer, but Rolfe just covered it all.

I could perhaps add a more general opinion: There is absolutely nothing wrong with adding whatever makes the patient feel better (whithout any real effect on the disease itself), as long as it is presented as: "This will not make you recover quicker or better, but it can improve your quality of life while we cope (or try to cope) with your disease through real medicine."

.. In otherwords, as long as it is clear that we are in the realm of palliative treatment. IN FACT, I could see a distinct advantage if some alternative treatment could take the place of conventional palliative treatment, but this would be a very individual thing.

Hans

Blue Wode

26th January 2009, 04:01 AM

I could see a distinct advantage if some alternative treatment could take the place of conventional palliative treatment, but this would be a very individual thing.

Hans

According to Professor Michael Baum, and others, that’s already being catered for on the UK NHS:
“We are sensitive to the needs of patients for complementary care to enhance well-being and for spiritual support to deal with the fear of death at a time of critical illness, all of which can be supported through services already available within the NHS without resorting to false claims.”

http://www.timesonline.co.uk/tol/news/uk/health/article723787.ece

Of course, as long as patients have been thoroughly evaluated by a medical doctor, understand that sCAM (for the most part) produces an unreliable placebo response, and are willing to foot the bill for their treatment themselves, then there’s not much that can be done to prevent them from taking the sCAM route as a supplement to (or even an alternative to) conventional treatment if that is their wish.

fls

26th January 2009, 04:08 AM

It is relatively well accepted that even water and sugar will produce *an* effect; when you say that homeopathy, for example, is "ineffective" what you really mean is that it is no more detectably effective than placebo. That is not the same as comparing it to no treatment at all.

The effect you refer to is basically a measure of patient satisfaction, since it doesn't represent any change in objective outcomes or the relief of subjective outcomes. Why not simply use other means of raising satisfaction, like a nice cuppa tea with a sympathetic listener, instead of using something that depends upon lying to your patients and interferes with the integrity of the doctor-patient relationship?

Linda

Rolfe

26th January 2009, 04:37 AM

Ivor the Engineer

26th January 2009, 04:51 AM

Or, as Soapy Sam keeps advocating, hairdressing therapy. Nice cup of the beverage of your choice, sympathetic listener who is trying their best to make you look good, and in the end you come away looking good and with an improved self-image.

Rolfe.

Perhaps it's different for women (and Soapy Sam:)), but I've always considered having my hair cut a bit of a chore. About the best 'response' I have is wanting to drop off to sleep, but usually that is prevented by the hairdresser asking me the same set of questions I gave answers to the last time I was in.

ETA: I come away with tiny pieces of hair which have dropped down the back of my neck and are incredibly itchy.

saizai

26th January 2009, 09:01 PM

Are you saying that it's ethical to lie to someone about a medical condition?

Personally, I think it's more ethical to be honest that there is never a 100% guarantee for any treatment to result in a "cure." Especially since there are a ton of medical conditions for which there is no cure, just the temporary alleviation of symptoms.

I'm saying the ethics are unclear.

One ethical principle is not to lie; another is to do things that make others feel better. Doctors are required to do both.

In this case, there is a conflict, in that raw truth - especially if not very tactfully presented - can be very upsetting and diminish the patient's quality of life. Saying that things will be definitely better might make them feel confident (and thus be happier), EVEN IF their physical outcome is identical.

I don't consider myself in a position to decide where along that spectrum one should treat any particular patient; that's obviously very dependent on circumstance and personality. I'm just saying it's ambiguous.

I'm also saying that not all doctors who are good *clinicians* are good *therapists*. The skills required to be technically proficient at treating physical ailments are not all that correlated with the ones required to make someone feel good about it.

Surgeons are great at the former; acupuncturists are great at the latter; good GPs are somewhere inbetween.

Supplementary alternative medicine would only be pointful in remedying the deficiencies in the primary doctor's *theraputic* ability.

Do you have any evidence of this?

Sure: people go to alternative medicine treatments, despite first trying standard medicine.

Conclusion: many doctors suck at the psychological aspects of treatment.

Some of the techniques are quite time-consuming, and they involve a lot of patient contact with the "therapist". This tends to be a positive thing in chronically ill patients where stress and anxiety are often significant contributors to decreased well-being. Many cancer centres include things like this for exactly that reason.

Indeed. I should point out that a priori I expect that most any treatment that gets at this should serve the job - whether it be 'hairdresser treatment' or dancing with puppies or acupuncture. The point is, current medical practice is deficient in it, and current 'alternative' practice has it down pat.

However, it's the element of lying which often creeps in that is so pernicious. It's one thing to provide hypnotherapy and massage therapy as aids to relaxation. It's quite another to provide complementary therapies with the explicit or implicit claim that there is actual medical benefit involved.But there is. You're just restricting what you consider "actual medical benefit".

Is pain relief "actual medical benefit"? Increased score on QoL surveys? Even if it doesn't make e.g. cancer any less fatal?

Or do you really think that misleading seriously ill patients with false hope is a good thing?I think that's a personal and social question that neither of us is qualified to answer on behalf of everyone.

Some people would rather not know. Some would. It's not for me to judge between grim informedness and blissful naïvété.

Then there is the additional problem that using alternative therapies in this way tends to legitimise them in the eyes of the public. So, a reflexologist and reiki practitioner (for example) who has nothing at all to do with this complementary use of the method, will then tout for business by claiming endorsement from the medical profession.

Valid problem. This could be addressed by having better regulation of the limitations AND benefits of alternative treatments, and ensuring people know what those are.

E.g. chiropractors get to say they'll make your back feel better, but not that they'll cure blindness and allergies. The same should hold of others' scopes.

Dismissing it entirely as "useless" is, IMO, a bad move by skeptics. It sets up a "Reefer Madness" type situation, where the public knows it's being lied to because it contradicts their personal experience (if you claim that acupuncture etc do *nothing*) and then don't pay attention when you're actually telling the truth (eg about the limitations of those therapies).

"No more than placebo" is not "nothing". Psychological benefits are very real and very much part of treating someone's overall problem - even if it has nothing to do with the duration of their illness or mortality rate. (And I'm not convinced that this is always true, even. Top-down effects may be smaller, but they're still present.)

Hairdressing works just as wellCite your source for this claim please?

and involves no lying to the patientEver heard a hairdresser tell you "you look great!"? :D

A final problem with these techniques is that they are often portrayed as some sort of "self-help" therapy.See above - the problem is in defining "medical benefit".

I think your problem with these is the "Law of Attraction" effect, aka the "Just World fallacy". People blame themselves for the stuff they can't affect, like their cancer.

My point, above, is that one can ethically concentrate on the *psychological* aspects of it. I see no particular reason why one needs to tell any lies, like "this will make the cancer go away". One can just say (truthfully) "this will make you feel better".

They shouldn't be led to believe that if they are feeling miserable and can't shake that off, that this is actually decreasing their chances of survival. Most importantly, if things do take a turn for the worse, they should not be led to believe that this is their own fault, and that if only they'd worked harder on that positive attitude they wouldn't have suffered the relapse or the recurrence.Oh, most definitely agreed. That sort of thing is kinda disgusting, really - but more to the point, it's the symptom of the 'therapist' going away from doing what's best for the patient's psychological well-being and into doing what's best for vindicating their own belief system.

I don't believe, however, that that is *necessary*; it's merely common.

Note that I did not specify what "alternative treatment" I was referring to, in the OP; I intentionally left it open. One could add caveats as to the kind of treatment that does fit in that category one would consider ethical.

It's not nearly as clear-cut or no-lose as you seem to think it is.I think, from what I've written and quoted above, that I'm the less cut-and-dry-framing of the two of us.

There is absolutely nothing wrong with adding whatever makes the patient feel better (whithout any real effect on the disease itself), as long as it is presented as: "This will not make you recover quicker or better, but it can improve your quality of life while we cope (or try to cope) with your disease through real medicine."

So are you saying that making the patient "feel better" does not make them "recover ... better"?

What does "better" mean in the latter case?

Suppose e.g. they need fewer pain medications as a result of their "feeling better"; would that count as "recovering better"?

The effect you refer to is basically a measure of patient satisfaction, since it doesn't represent any change in objective outcomes or the relief of subjective outcomes.

So you're saying that patient satisfaction is not a subjective outcome, nor is it something that can be objectively measured?

Why not simply use other means of raising satisfaction, like a nice cuppa tea with a sympathetic listener, instead of using something that depends upon lying to your patients and interferes with the integrity of the doctor-patient relationship?Tea with a sympathetic person is a perfectly valid alternative treatment as far as I'm concerned.

It's not currently administered with any regularity in any hospitals I know of.

I think you're making unfounded assumptions about what the treatment involved, given that you think it necessarily involves lying.

SkeptiChick

26th January 2009, 10:12 PM

I'm saying the ethics are unclear.No, they're not unclear.

One ethical principle is not to lie; another is to do things that make others feel better. Doctors are required to do both.It is not a doctor's responsibility to make a patient feel better about their situation. it is a doctor's responsibility to adhere to a certain level of care.

In this case, there is a conflict, in that raw truth - especially if not very tactfully presented - can be very upsetting and diminish the patient's quality of life. Saying that things will be definitely better might make them feel confident (and thus be happier), EVEN IF their physical outcome is identical.Saying that things will definitely be better would be offering a guarantee, which would leave the doctor open to possible legal repercussions, as well as could potentially damage the patient's state of mind if things don't eventually get better. Lying to a patient about the severity of their condition is NEVER the right thing to do.

I don't consider myself in a position to decide where along that spectrum one should treat any particular patient; that's obviously very dependent on circumstance and personality. I'm just saying it's ambiguous.And yet, it's not ambiguous.

I'm also saying that not all doctors who are good *clinicians* are good *therapists*. The skills required to be technically proficient at treating physical ailments are not all that correlated with the ones required to make someone feel good about it.Clinicians are not supposed to be therapists. There are actual therapists who's job it is to counsel people. If a patient is in need of emotional support because of a severe illness, doctors will refer them to a therapist or counselor.

Surgeons are great at the former; acupuncturists are great at the latter; good GPs are somewhere inbetween.Surgeons and GP's are not supposed to be mental health specialists. Neither are acupuncturists. If someone is in need of mental health care, they should see a mental health specialist.

Supplementary alternative medicine would only be pointful in remedying the deficiencies in the primary doctor's *theraputic* ability.Again, the doctor one sees for physical ailments is different than what one would see for mental/emotional health issues.

<snip>
Conclusion: many doctors suck at the psychological aspects of treatment.They're not supposed to be good at it. Psychologists, psychiatrists, mental health therapists and counselors are.

Indeed. I should point out that a priori I expect that most any treatment that gets at this should serve the job - whether it be 'hairdresser treatment' or dancing with puppies or acupuncture. The point is, current medical practice is deficient in it, and current 'alternative' practice has it down pat.Current medical practice is not deficient in dealing with the psychological aspects of illness. In fact, there is a whole subset of the medical field that specializes in just that.

Valid problem. This could be addressed by having better regulation of the limitations AND benefits of alternative treatments, and ensuring people know what those are.How about getting rid of these redundant charlatans entirely? You can get just as much benefit from seeing a mental health professional as you can from downing nameless herbal concoctions, or being stuck with needles (that may or may not be clean), or having your spine manipulated, with far less physical risk.

Dismissing it entirely as "useless" is, IMO, a bad move by skeptics. It sets up a "Reefer Madness" type situation, where the public knows it's being lied to because it contradicts their personal experience (if you claim that acupuncture etc do *nothing*) and then don't pay attention when you're actually telling the truth (eg about the limitations of those therapies).It's not just that these things are useless. These alternative "treatments" can be dangerous, and often times the practitioners of such things encourage people with serious medical conditions to forgo real medical intervention.

I think your problem with these is the "Law of Attraction" effect, aka the "Just World fallacy". People blame themselves for the stuff they can't affect, like their cancer.

My point, above, is that one can ethically concentrate on the *psychological* aspects of it. I see no particular reason why one needs to tell any lies, like "this will make the cancer go away". One can just say (truthfully) "this will make you feel better".Seeing a mental health professional, some one who is certified and trained to access and treat someone's mental health is a much more ethically sound choice than advocating someone seeing untrained, unregulated persons who are pushing snake oil.

So are you saying that making the patient "feel better" does not make them "recover ... better"?

What does "better" mean in the latter case?

Suppose e.g. they need fewer pain medications as a result of their "feeling better"; would that count as "recovering better"?Someone needing fewer pain pills because their psychological situation improves is indicative of a mental health issue that needs real treatment (such as clinical depression that can cause or increase chronic pain issues, or even hypochondria). And in that case, having real treatment provided instead of a snake oil offering might cause markedly better improvement, if not resolve the situation entirely.

Tea with a sympathetic person is a perfectly valid alternative treatment as far as I'm concerned.

It's not currently administered with any regularity in any hospitals I know of.I think you may want to rethink that. The last time I was in hospital I had a really great nurse who just sat down and talked with me for a while. The time before that, I had several nurses who did the same. In fact, everyone I've ever known who spent time in hospital had similar experiences. There may not have been tea involved, but the "psychological well-being" aspect was definitely NOT ignored.

I think you're making unfounded assumptions about what the treatment involved, given that you think it necessarily involves lying.How, exactly, is having a GP tell you that "things definitely will get better," when there is no guarantee of that NOT lying? Don't you realize how much damage that kind of lie can do to a person? How about to their extended family? You're not advocating better care here. You're basically saying that doctors should sink to the same level that alt-care providers do with their dishonest charlatanry.

Mojo

27th January 2009, 02:55 AM

"Complementary" is the term for woo-woo techniques applied as an add-on to conventional treatment.

...

However, it's the element of lying which often creeps in that is so pernicious. It's one thing to provide hypnotherapy and massage therapy as aids to relaxation. It's quite another to provide complementary therapies with the explicit or implicit claim that there is actual medical benefit involved. What can happen is that the therapy is provided in good faith as a combination of relaxation and occupational therapy, but the therapist herself (they're usually female) is convinced that her method can actually influence the disease process and says so; so patients are misled with false hopes.

...

Then there is the additional problem that using alternative therapies in this way tends to legitimise them in the eyes of the public. So, a reflexologist and reiki practitioner (for example) who has nothing at all to do with this complementary use of the method, will then tout for business by claiming endorsement from the medical profession.

Another problem (or if you're a CAMster, an advantage) is that if "complementary medicine" is used alongside or after conventional treatment the "compelementary treatment will often be given the credit for any improvement caused by the conventio9nal treatment.

Rolfe

27th January 2009, 02:57 AM

What SkeptiChick said, basically.

And could we quit with this "supplementary alternative" thing? We've explained to you that the accepted standard term for what you're talking about is "complementary therapy" (note the spelling - "complimentary therapy" is where the therapist makes you feel better by telling you how nice you look and how smart you are - hey, maybe not much difference there then). Calling it something else, especially a combination of words for other things, is confusing and unhelpful.

Rolfe.

fls

27th January 2009, 03:45 AM

So you're saying that patient satisfaction is not a subjective outcome, nor is it something that can be objectively measured?

Patient satisfaction is also a subjective outcome.

Tea with a sympathetic person is a perfectly valid alternative treatment as far as I'm concerned.

It's not currently administered with any regularity in any hospitals I know of.

I think you're making unfounded assumptions about what the treatment involved, given that you think it necessarily involves lying.

You don't really seem to be talking about alternative and complementary medicine, since these are modalities for which therapeutic claims are made. You simply seem to be talking about things like bedside manner. And I think you are grossly over-estimating the extent to which alternative practitioners have any sort of advantage in this regard. Once you take away their ability to provide temporary reassurance through lying, their advantage is only situational and can easily be transferred to conventional settings. If you have the resources for someone to act as a sympathetic listener, then apply them to the doctors, nurses, social workers, etc. that are already working with the patients. And if you applied SCAM to a general population of patients, you would soon discover that the outcomes are different than when it is applied to a population pre-selected to do well.

ETA: The correct term isn't really 'lies', but rather '********' (per http://press.princeton.edu/titles/7929.html).

Linda

fls

27th January 2009, 03:46 AM

I have to say, I'm really liking this Complimentary Therapy idea. :)

Linda

Mojo

27th January 2009, 03:47 AM

"complimentary therapy" is where the therapist makes you feel better by telling you how nice you look and how smart you are - hey, maybe not much difference there then.

Or therapy that they don't charge you for, which I suspect would make it radically different from most CAM.

MRC_Hans

27th January 2009, 04:49 AM

I'm saying the ethics are unclear.

One ethical principle is not to lie; another is to do things that make others feel better. Doctors are required to do both.

Nothing unclear. The duty of a doctor is not to make people feel better, it is to cure them, or, failing that, reduce their suffering.

In this case, there is a conflict, in that raw truth - especially if not very tactfully presented - can be very upsetting and diminish the patient's quality of life. Saying that things will be definitely better might make them feel confident (and thus be happier), EVEN IF their physical outcome is identical.

The fact that some physicians are not apt at presenting bad news is not a reason for them to lie, and even less reason for others to lie.

Some people would rather not know. Some would. It's not for me to judge between grim informedness and blissful naïvété.

It is irrelevant for the topic. It can be discussed how (and if) bad news should be passed to the patient, but that has nothing to do with SCAM.

Dismissing it entirely as "useless" is, IMO, a bad move by skeptics.Maybe, maybe not. We tend to prefer the truth over propaganda value, however.

So are you saying that making the patient "feel better" does not make them "recover ... better"?

Generally, yes.

What does "better" mean in the latter case?

Improved objective outcome.

Suppose e.g. they need fewer pain medications as a result of their "feeling better"; would that count as "recovering better"?

Only in terms of avoiding possible side-effects of pain mediciation (a genuine concern). However, SCAM has very limited scope for doing that, if any.

Hans

Yuri Nalyssus

27th January 2009, 03:19 PM

I come away with tiny pieces of hair which have dropped down the back of my neck and are incredibly itchy.
That's known as an aggrivation and is a sign that hairdressing has a measurable effect.

Isn't it always a disappointment when a CAM practitioner offers you "something for the weekend, sir" and it turns out to be a residential DNA re-alignment course or something; that's why I choose Hairdressing - because I'm worth it ;).

Yuri

saizai

27th January 2009, 03:59 PM

No, they're not unclear.

It is not a doctor's responsibility to make a patient feel better about their situation. it is a doctor's responsibility to adhere to a certain level of care.

So you'd be okay with a doctor saying "you're ****ed and probably going to die within a year from your cancer. I can't do anything for you. Bye." ?

There are lots of ways of dealing with the same underlying facts.

"This American Life" had a segment about this about a year? ago, but I can't find it.

Clinicians are not supposed to be therapists. There are actual therapists who's job it is to counsel people. If a patient is in need of emotional support because of a severe illness, doctors will refer them to a therapist or counselor.

Surgeons and GP's are not supposed to be mental health specialists. Neither are acupuncturists. If someone is in need of mental health care, they should see a mental health specialist.

Again, the doctor one sees for physical ailments is different than what one would see for mental/emotional health issues.

They're not supposed to be good at it. Psychologists, psychiatrists, mental health therapists and counselors are.

Current medical practice is not deficient in dealing with the psychological aspects of illness. In fact, there is a whole subset of the medical field that specializes in just that.

I find that to be pretty blinkered.

The fact is, most people who go for treatment of a serious medical condition have both biological and psychological aspects of their problem.

Most don't go to see a psychiatrist, for many reasons - stigma, cost, momentum, etc. But they do seek other things (be they hairdresser or acupuncturist) that serve some aspects of that problem.

I don't see why that's a bad thing a priori - especially when people like you actually encourage doctors to not give a **** about their patients as humans, but only as biological organisms, and that lack makes patients feel worse about their treatment.

But then, you probably would also say that standard medicine has nothing to do with how people feel, just whether their physical symptoms are fixed, so those outcomes are irrelevant...

How about getting rid of these redundant charlatans entirely? You can get just as much benefit from seeing a mental health professional as you can from downing nameless herbal concoctions, or being stuck with needles (that may or may not be clean), or having your spine manipulated, with far less physical risk.

No argument there. But nevertheless people seem to often prefer the latter over the former. Why would that be, if the former is (supposedly) better in every way?

Someone needing fewer pain pills because their psychological situation improves is indicative of a mental health issue that needs real treatment (such as clinical depression that can cause or increase chronic pain issues, or even hypochondria).

Not necessarily so. Studies showing that induced mental state (e.g. listening to music, being lied to that one has taken an opiate, etc) dramatically affects pain perception and tolerance are a staple of even basic cogsci / neuro classes.

In fact, that is one example of where lying may be medically more ethical.

Placebo "opiates" are, in the short term, actually pretty good for a large proportion of patients for mild to moderate pain - with much less expense, inducement of side effects, drug interactions, interactions with various immunological disorders. It doesn't last as long, and it's not *as* good as real opiates, but sometimes one doesn't really need something that *is* that strong... even though the patient might feel strongly that they need it.

Therefore, placebo pills may sometimes be an objectively better treatment than real ones. And that requires lying.

I think you may want to rethink that. The last time I was in hospital I had a really great nurse who just sat down and talked with me for a while.

Then you were at an unusually good hospital, I think.

Not everyone gets that.

How, exactly, is having a GP tell you that "things definitely will get better," when there is no guarantee of that NOT lying? Don't you realize how much damage that kind of lie can do to a person? How about to their extended family? You're not advocating better care here. You're basically saying that doctors should sink to the same level that alt-care providers do with their dishonest charlatanry.

You're taking that out of context; that was purely part of a sub-argument about the ethics of lying vs compassion. I am not advocating it, and it is not what I was talking about in the OP. Don't try to paint it as if that's the whole point of my argument.

You simply seem to be talking about things like bedside manner.

... which the above poster believes has nothing to do with medicine, and should not be expected of non-psychiatric doctors. :)

And anyway, not just that. Doctors' visits are rarer than people need support.

their advantage is only situational and can easily be transferred to conventional settings. If you have the resources for someone to act as a sympathetic listener, then apply them to the doctors, nurses, social workers, etc. that are already working with the patients.

Oh, sure. I haven't said anything about it not being possible for these aspects of treatment to be done conventionally.

I said it's not routinely done currently except in alternative medicine circles, and as you can see above, not everyone even believes it's something that doctors should care about at all.

Thus, there is - and probably will be for some time to come - a lack of coverage of this aspect of patient care. That lack is addressed by some alternative treatments. Thus, those alternative treatments continue to have utility.

If hospitals etc routinely integrated psychological care, then maybe this would change. But currently, per the above poster, doctors only do your body; you have to go to a shrink if you want to merely "feel better".

Not what I'd call comprehensive treatment.

Nothing unclear. The duty of a doctor is not to make people feel better, it is to cure them, or, failing that, reduce their suffering.

So "making them feel better" is not the same thing as "reducing their suffering"?

Please explain. :D

The fact that some physicians are not apt at presenting bad news is not a reason for them to lie, and even less reason for others to lie.

I didn't say that it was. I said there are many ways to deal with the same biological conditions, some of which are better or worse for the psychological well-being of the patient.

Maybe, maybe not. We tend to prefer the truth over propaganda value, however.

You do. It's arrogant for you to say that everyone should.

Some people would rather not know. Would you say that they should be required to?

fls

27th January 2009, 04:41 PM

Oh, sure. I haven't said anything about it not being possible for these aspects of treatment to be done conventionally.

I said it's not routinely done currently except in alternative medicine circles, and as you can see above, not everyone even believes it's something that doctors should care about at all.

Thus, there is - and probably will be for some time to come - a lack of coverage of this aspect of patient care. That lack is addressed by some alternative treatments. Thus, those alternative treatments continue to have utility.

If hospitals etc routinely integrated psychological care, then maybe this would change. But currently, per the above poster, doctors only do your body; you have to go to a shrink if you want to merely "feel better".

Not what I'd call comprehensive treatment.

But that's simply a function of the circumstances under which visits to an alternative provider take place. If you give a conventional practitioner a group of patients in whom serious disease has already been ruled-out, with no third-party payers breathing down their neck, no need for professional development like continuing medical education, no ethics to violate, and the freedom to disregard the truth, they would also be able to make frequent visits and provide glib reassurance as skillfully as any alternative practitioner.

And I think you can safely ignore the perceptions from people who don't actually work within the field. Of course, providing hope, tactful and sympathetic communication, and addressing questions and concerns is of interest to conventional practitioners.

Linda

Ivor the Engineer

28th January 2009, 01:25 AM

But that's simply a function of the circumstances under which visits to an alternative provider take place. If you give a conventional practitioner a group of patients in whom serious disease has already been ruled-out, with no third-party payers breathing down their neck, no need for professional development like continuing medical education, no ethics to violate, and the freedom to disregard the truth, they would also be able to make frequent visits and provide glib reassurance as skillfully as any alternative practitioner.

Some people find empathy easy, some find empathy hard, others (such as myself:)) find empathy virtually impossible. From my (albeit limited) experience, I'm not sure physicians as a group are very much different from the reset of society in this ability.

fls

28th January 2009, 02:06 AM

Some people find empathy easy, some find empathy hard, others (such as myself:)) find empathy virtually impossible. From my (albeit limited) experience, I'm not sure physicians as a group are very much different from the reset of society in this ability.

Ditto for alternative practitioners.

Linda

MRC_Hans

28th January 2009, 02:27 AM

*snip*
So "making them feel better" is not the same thing as "reducing their suffering"?

Please explain. :D
*snip*

Not necessarily. Reduce suffering can refer to reduce the reasons for suffering, e.g. reduce pain. Feel better can refer to changing the way the patient copes.

But all this nitpicking (which also includes the rest of your answers) is really irrelevant for your basic question: Are alternative (and non-verified) treatments ethical for supplementary treatment?

What you are doing is moving the discussion to be one about whether patients need something other than strict medical intervention, and I don't really think anybody will say no to that.

The question is: Can unverified alternative methods accomplish that?

Hans

Ivor the Engineer

28th January 2009, 02:54 AM

Ditto for alternative practitioners.

Linda

I disagree. I think because 'good bedside manner' is all alternative medical practitioners have going for them, those that do not have this ability would not last very long, whereas a physician can be a objectionable and/or miserable git and still be useful.

fls

28th January 2009, 04:01 AM

I disagree. I think because 'good bedside manner' is all alternative medical practitioners have going for them, those that do not have this ability would not last very long, whereas a physician can be a objectionable and/or miserable git and still be useful.

I suspect that any selection pressure is weak considering that there isn't much of a barrier to the appearance of sympathy.

Linda

Rolfe

28th January 2009, 04:08 AM

What Hans said. Definitely.

But let's focus on the main point here.

First, you really need to get rid of these straw men.

So you'd be okay with a doctor saying "you're ****ed and probably going to die within a year from your cancer. I can't do anything for you. Bye." ?

There are lots of ways of dealing with the same underlying facts.

Yes, there are a lot of ways of dealing with the same underlying facts, and that one is inexcusable. The implication that not lying to your patient equates to the inevitability that sort of insensitivity is ridiculous. I very much doubt that there is any doctor on the face of the globe who would be as callous as that.

Certainly, it's inevitable some doctors will be a tad deficient in the bedside manner tact department. This is being tackled by some very serious training in patiant management and interpersonal skills in modern medical courses. No doubt there are still deficient individuals. Nevertheless there are also doctors who are absolutely wonderful in this area.

Do you really think the solution to the problem of the remaining inadequate individuals is to sanction the employment of unqualified personnel to lie to the patient?

You seem to be suggesting that lying to the patient is justifiable and indeed beneficial. So, if we're going to lie to patients, why not just let the doctors do it and cut out the middle-man?

Yes, I can see the disadvantage. If doctors are known to be lying to patients when they feel it might make them feel better, then how can we trust a single word any doctor says?

So your solution is to out-source the lying. Employ people who genuinely believe the most outlandish things, validate and sanction these beliefs by incorporating these people within the medical establishment (oh yes, and pay them quite a lot of money), and then let them tell the poor patients a pack of lies about how the sugar pills or the energy field manipulation will cure them?

Sorry, as a solution to the problem of a proportion of doctors lacking the time and/or skills to handle their patients as people, it's not striking me as being terribly sensible.

Rolfe.

shawmutt

28th January 2009, 04:11 AM

Jeez, everything I had to say on the subject is covered--that's nice for a change :D Usually I'm the lone wolf against faith-based scams--the closed-minded shill.

All I have to add is an analogy--Allowing scam artists to peddle their faith-based (complimentary/alternative/woo woo/or whatever you want to call it) medicine simply because the patient thinks he feels better is like saying pyramid schemes should be legal because people think they're making money!

T.A.M.

28th January 2009, 04:15 AM

Rolfe

28th January 2009, 04:27 AM

Jeez, everything I had to say on the subject is covered--that's nice for a change :D Usually I'm the lone wolf against faith-based scams--the closed-minded shill.

Ah, you must be new here! :D

Welcome.

Rolfe.

SkeptiChick

28th January 2009, 01:34 PM

Hans and Rolfe covered most of what I wanted to say, so I'm only going to address a small bit here. Before I do that though, please stop with the strawmen and veiled personal attacks. It does nothing to further your cause, instead making it out like you've run short of viable arguments.

I find that to be pretty blinkered.

The fact is, most people who go for treatment of a serious medical condition have both biological and psychological aspects of their problem.Which is why there are support groups for just about everything under the sun, as well as mental health specialists if the psychological aspects are serious enough.

Most don't go to see a psychiatrist, for many reasons - stigma, cost, momentum, etc. But they do seek other things (be they hairdresser or acupuncturist) that serve some aspects of that problem.I'm sorry, but you seem to be advocating seeking an alternative treatment instead of seeing a qualified, certified, medical specialist. And you're advocating it because... People just don't want to go? You seem to be contradicting the point of this thread -- that alternative treatment should not replace real medical treatment, and should only be allowed as a "supplement" (complimentary treatment).

See, the problem is, if we allow your argument as a justification for seeking alternative treatment in terms of mental health, then we also have to allow the same argument for other fields of medicine.

Do you think it's okay for a cancer patient to not see an oncologist because of "stigma, cost, momentum, etc." and instead seek out a faith healer? I certainly don't.

How about going to a dentist? Should one forgo that just because they are uncomfortable around dentists, and instead seek out a cup of tea and a long talk about how their rotting teeth make them feel unattractive? Hmm?

<snipped derisive comments>

No argument there. But nevertheless people seem to often prefer the latter over the former. Why would that be, if the former is (supposedly) better in every way?Why do people prefer spending money on snake oil instead of actual treatment? Well, part of it has to do with the fact that they are lied to, and convinced (by playing upon emotions and social stigmas) that the snake oil is better than the real treatment. It offers instant gratification, when real treatment requires time and effort. It claims to be "cheaper" than real treatment when it isn't. It claims to be "more caring towards the individual" when it isn't -- it's only care for the individual is how deep their pockets are, or how much cash can be squeezed out of them. It tells them exactly what they want to hear instead of telling them what they need to hear.

Unfortunately just because something is better, or more effective, that doesn't mean it's more pleasant.

Not necessarily so. Studies showing that induced mental state (e.g. listening to music, being lied to that one has taken an opiate, etc) dramatically affects pain perception and tolerance are a staple of even basic cogsci / neuro classes.Music and relaxation techniques are things that are taught by mental health specialists. Ever heard of cognitive behavioral therapy?

In fact, that is one example of where lying may be medically more ethical.

Placebo "opiates" are, in the short term, actually pretty good for a large proportion of patients for mild to moderate pain - with much less expense, inducement of side effects, drug interactions, interactions with various immunological disorders. It doesn't last as long, and it's not *as* good as real opiates, but sometimes one doesn't really need something that *is* that strong... even though the patient might feel strongly that they need it.

Therefore, placebo pills may sometimes be an objectively better treatment than real ones. And that requires lying.The problem here is one of trust. As stated previously by others. If my doctor is allowed to lie to me (without my actively agreeing that he's allowed to, as in a study where the possibility that I might be given the placebo is disclosed and agreed to in writing), then how can I trust anything he says?

Then you were at an unusually good hospital, I think.

Not everyone gets that.No, I wasn't at an unusually good hospital. Both instances took place at different hospitals, and both of them were underfunded just like every other hospital is. And you ignored the part where I said that everyone I'd ever known who'd been at hospital had the same kind of experience. Were all those people (and there are quite a few of them, who've been in hospital at various locations across the US mind you) also at unusually good hospitals? No. Not unless there is a really huge number of "unusually" good hospitals. But if that's the case, its not really unusual then is it. Hm.

You're taking that out of context; that was purely part of a sub-argument about the ethics of lying vs compassion. I am not advocating it, and it is not what I was talking about in the OP. Don't try to paint it as if that's the whole point of my argument.And yet, it really does seem to be the whole of your argument as you are dismissing the viable medical treatments that would provide the level of compassion you think is required, and instead advocating an industry that lies and cheats its "patients" out of their life savings.

I don't happen to think that lying to someone is compassionate. Using tact? Sure. Being polite and respectful? Sure. Lying and trickery? No. Not compassionate, and definitely not polite or respectful. But you keep advocating it anyway, so I don't really think your argument has anything to do with compassion.

Some people would rather not know. Would you say that they should be required to?Some people would rather not know the truth. Agreed. However, pandering to someone's desire to go through life cluelessly does not lead to an ethically viable solution to their issues when it comes to medicine. If you don't tell a person what the actual problems are, and the actual treatments, how can they provide informed consent to that treatment? You know, that informed consent that is required by law? That informed consent which is required specifically to avoid patients being hornswaggled by persons of ill repute wishing to perform unnecessary or dangerous procedures with no care for the person who's life is being put at risk.

You simply can't have it both ways. Lying to patients is wholly unacceptable, no matter what spin you want to try and put on it.

saizai

28th January 2009, 04:48 PM

Not necessarily. Reduce suffering can refer to reduce the reasons for suffering, e.g. reduce pain. Feel better can refer to changing the way the patient copes.

Yet pain is definitely a mental process - as I referred to with the well-known placebo opiate experiments. Perception *is* reality when it comes to that domain.

What you are doing is moving the discussion to be one about whether patients need something other than strict medical intervention, and I don't really think anybody will say no to that.

The question is: Can unverified alternative methods accomplish that?

I think that's a perfectly acceptable way to recast the question.

IMO/E, the answer is yes.

Some variants (e.g. massage / group therapy) are more usually ethical than others (e.g. homeopathy), but they both provide at least this same underlying thing.

People clearly have different tastes as to what they prefer and are willing to do, though.

Do you really think the solution to the problem of the remaining inadequate individuals is to sanction the employment of unqualified personnel to lie to the patient?

First off: unqualified to do what, exactly?

Second: I gave only two examples where lying might be better for the patient:
1. when the patient would be excessively upset by news they can't do anything about anyway, and would rather not know; and
2. when a placebo would be better for the patient overall than the real thing

Neither of those were examples of alternative therapy as I've been using the term. I have not said anything about alt people having (or being encouraged to) lie to patients.

You're confusing things and making a straw man of your own.

Sorry, as a solution to the problem of a proportion of doctors lacking the time and/or skills to handle their patients as people, it's not striking me as being terribly sensible.

Let's face it, most mainstream doctors, especially hospitals, are currently overloaded - especially in larger cities. They simply don't have the time to do the touchy-feely stuff.

Other people do. Why not let 'em?

It doesn't require any knowledge of anatomy, cellular degeneration, chemotehrapy, etc. to do any of what I've been referring to.

Which is why there are support groups for just about everything under the sun, as well as mental health specialists if the psychological aspects are serious enough.

I'm sorry, but you seem to be advocating seeking an alternative treatment instead of seeing a qualified, certified, medical specialist. And you're advocating it because... People just don't want to go?

Basically, yes. People clearly have differing preferences and taboos.

Most modern cultures have major taboos about psychotherapy (in any form, including "support groups").

However, alt therapies provide much of the same effective support (socialization, feeling of empathy, touch, etc). They're like covert versions that don't trigger all the taboos.

To me it's just another way of accomplishing the same thing.

Do you think it's okay for a cancer patient to not see an oncologist because of "stigma, cost, momentum, etc." and instead seek out a faith healer? I certainly don't.

No, because oncology and dentistry are biological issues that cannot be addressed effectively without provable science and all that.

Mental health is not necessarily the same, and includes things like pain which are quite real, objective, measurable, and cost money in the form of pain medications and all the things that those medications mess up.

Again, you're making a straw man here.

And yet, it really does seem to be the whole of your argument as you are dismissing the viable medical treatments that would provide the level of compassion you think is required, and instead advocating an industry that lies and cheats its "patients" out of their life savings.

Exaggeration. Some do that sort of fraud, most don't.

Frauds exist in mainstream medicine too.

blutoski

28th January 2009, 04:54 PM

Suppose that an 'alternative' technique is made available, exclusively under the condition that it be used in conjunction with evidence-based medicine - e.g. it's only provided to people currently under treatment in a real hospital. Let's call this 'suppletive alternative treatment'.

It is relatively well accepted that even water and sugar will produce *an* effect; when you say that homeopathy, for example, is "ineffective" what you really mean is that it is no more detectably effective than placebo. That is not the same as comparing it to no treatment at all.

The main argument against placebo strategies is specifically that there is little evidence that there is an effect above and beyond nontreatment. Most of the 'placebo effect' is the illness' natural course of improvement.

Please read the Cochrane Collaboration's literature review. There is very little evidence that there is any improvement that can be attributed to taking a placebo that would not take place untreated.

The marginal evidence of improvement attributed to expectation is rarely greater than background noise, and that means it rarely has clinical significance.

It is because of this that I oppose dedicated placebo treatments.

One problem modern medicine has is that it kinda sucks at placebo effect creation. We no longer have (ethical) doctors who convince their patients that everything will be cured; who conduct nice rituals; who make patients really *feel* it as well as doing what happens to actually work better than placebo.

"Alternative medicine" practitioners, however, have this down pat. It is, after all, the entire crux of their services.

I think this is a bit of a myth, perpetuated by altmed apologists. Chiropractors aren't embarassed to have an assembly-line for a practice, cranking 200 patients through per day. They take professional credit courses to learn the latest technologies to minimize their time per patient.

My impression of the limited literature on this is that while this remains established in patient opinion, objective measures of patient care in different modalities doesn't really bear out a significant difference in empathy toward patients, or time spent per patient visit.

Having said that, even if there were a difference, it's an argument to modify conventional medicine's bedside manner, not an argument to pay extra for somebody else to provide it without actually treating anybody.

If suppletive alternative treatment were given, then, could it not be ethically, economically, and medically beneficial - simply in remedying this gap in addressing the human qualities?

If the assumptions you started with were true, there could be a discussion. As it is, the literature shows that there isn't much benefit in placebo treatments over nontreatment. The discussion really needs some facts, rather than 'what if' discussions.

It's sort of like those people who argue over whether telekenesis is quantum entanglement, skipping the step of actually showing telekenesis exists in the first place.

The one ethical problem I can see with it is that, because it feels better than the "real" stuff, people may overattribute their recovery to it, and thus be tempted to abandon the evidence-backed medicine, to their medical detriment. This is at least partially allayed by exclusively providing this treatment in the context of evidence-backed better-than-placebo care.

Your opinion?

I think you'll have to start with showing good examples of placebo care providing any benefits at all over nontreatment.

There's a whiff of a hint that it may influence chronic pain, but that's about it, and no way to tell if it's just a patient reporting error.

SkeptiChick

28th January 2009, 05:38 PM

Yet pain is definitely a mental process - as I referred to with the well-known placebo opiate experiments. Perception *is* reality when it comes to that domain.

I think that's a perfectly acceptable way to recast the question.

IMO/E, the answer is yes.

Some variants (e.g. massage / group therapy) are more usually ethical than others (e.g. homeopathy), but they both provide at least this same underlying thing.

People clearly have different tastes as to what they prefer and are willing to do, though.

First off: unqualified to do what, exactly?

Second: I gave only two examples where lying might be better for the patient:
1. when the patient would be excessively upset by news they can't do anything about anyway, and would rather not know; and
2. when a placebo would be better for the patient overall than the real thing

Neither of those were examples of alternative therapy as I've been using the term. I have not said anything about alt people having (or being encouraged to) lie to patients.

You're confusing things and making a straw man of your own.

Let's face it, most mainstream doctors, especially hospitals, are currently overloaded - especially in larger cities. They simply don't have the time to do the touchy-feely stuff.

Other people do. Why not let 'em?

It doesn't require any knowledge of anatomy, cellular degeneration, chemotehrapy, etc. to do any of what I've been referring to.

Basically, yes. People clearly have differing preferences and taboos.

Most modern cultures have major taboos about psychotherapy (in any form, including "support groups").

However, alt therapies provide much of the same effective support (socialization, feeling of empathy, touch, etc). They're like covert versions that don't trigger all the taboos.

To me it's just another way of accomplishing the same thing.

No, because oncology and dentistry are biological issues that cannot be addressed effectively without provable science and all that.

Mental health is not necessarily the same, and includes things like pain which are quite real, objective, measurable, and cost money in the form of pain medications and all the things that those medications mess up.

Again, you're making a straw man here.

Exaggeration. Some do that sort of fraud, most don't.

Frauds exist in mainstream medicine too.
I was going to try to respond to this point by point... But since your points seem to contradict one another I'm not going to bother.

You seem to be discussing an array of subjects which you know nothing about. This is evident due to a number of contradictions in what you've said. i.e. pain is about perception, but it is objective and measurable.

Pain is not objective, nor is it measurable (yet, there are research projects in the works attempting to come up with a measurement). If you insist on stating that it is, please provide the unit of measure for pain as some sort of evidence.

You insist that seeing an alt therapist for mental health issues instead of a mental health specialist is not the same as seeing an alt therapist for cancer instead of an oncologist. How is it different? Both are schools of medicine. Both involve scientifically documented and peer reviewed observations, and mental health also includes one's physiology (hormonal and chemical imbalances for example).

You say that you think it would be good if alt therapies required one to be undergoing concurrent actual medical treatment. And yet, when it is shown that psychological issues have licensed and certified medical practitioners, you say that people shouldn't have to make use of those because of personal preference. Well, what about the personal preference of the person who doesn't want to see an oncologist because of the stigma of "having cancer"? It's okay for the mental health industry to be brushed to the side because of personal preference, but not oncology? It's okay for you to say that someone has to seek medical treatment in addition to their alt therapy for cancer, but not for a mental health issue? Uh huh.

As for fraud in alt therapies -- ALL alt therapies are fraudulent. 100% are. Why? Because science has shown them to fail at all their claims. These "therapies" can't even stand up against NO treatment, let alone other medications in clinical trials. So, any practitioner of those alt therapies who says that those things are anything other than an emotional band-aid is lying. And guess what? ALL practitioners of alt therapies say that what they do is other than an emotional band-aid. They all claim that they can cure disease X or prevent condition Y. Every. Last. One. Of. Them.

But you obviously don't care about that, as you're the one here advocating that doctors should lie to their patients, and undermine every step towards a trusting doctor patient relationship.

What part of "lying is bad for people" do you not get? I mean, most people learned that lying gets you nowhere while they were still in elementary school, but here you are advocating that the people we trust to take care of us as adults lie to us about serious medical conditions! Don't you see the sheer lunacy of such a proposition? If not on a medical or scientific level, at least on a social one?

blutoski

29th January 2009, 01:28 PM

Yet pain is definitely a mental process - as I referred to with the well-known placebo opiate experiments. Perception *is* reality when it comes to that domain.

I noticed that SkeptiChick took exception to this in her post above, and would like to address it a bit.

Pain clearly has a subjective reporting and coping aspect, but it's obviously very real. Unfortunately, it's hard to measure objectively - but we can measure its effect on the patient.

The best methods are proxy methods like that. Does this pain relief method improve range of motion in a joint? Is the patient able to resume more and more enjoyable activities, previously prohibited by pain? From these objective metrics that we assume an underlying change in pain perception. These are the best we have, and there is a risk of reification - falsely believing that improvement in reported pain is an improvement in actual pain. But it's not ridiculous to tentatively treat them as equivalent when considering the purpose of medicine is to improve patient metrics' outcomes.

Nevertheless, there are reasonable questions about what this means in terms of efficacy of the treatment that generated the improved outcome.

To illustrate the problem, consider range-of-motion tests. Patient is given the 'ritual' (nonblinded placebo-type) treatment and when tested shows improved range in the joint compared to nontreatment. There are several explanations:

patient has reduced pain
doctor is a true believer, and is more encouraging and persistent
patient doesn't want to disappoint the doctor, so pushes through the pain, undergoing more discomfort than in baseline tests

The expression we use is "distinguish from bias" - before we start recommending running up a customer's credit card, we have to know a bit more about how the placebo ritual influences the measureable outcome. If the mechanism is that customer are gritting their teeth and pushing through pain just to make the physician happy, I can't understand why there's an argument that this is in any way ethical. Especially considering the lack of evidence for clinically relevant improvement.

First off: unqualified to do what, exactly?

Second: I gave only two examples where lying might be better for the patient:
1. when the patient would be excessively upset by news they can't do anything about anyway, and would rather not know; and

This actually alarms me, because one of the boilerplate complaints about allopathic doctors is that they are pedantic jackasses who think they know what's good for the patient without even engaging them. Within medicine, this attitude is considered unethical, and so medical ethics as we know it is fundamentally based on collaboration with the patient.

This sounds like an attempt to jettison the fundamental patient right of disclosure.

2. when a placebo would be better for the patient overall than the real thing

This is the core debate: is there such a situation? Or are we asking an hypothetical fantasy question like, "if magic existed, should we use it in medicine?" or "How many angels can dance on the head of a pin?"

Let's face it, most mainstream doctors, especially hospitals, are currently overloaded - especially in larger cities. They simply don't have the time to do the touchy-feely stuff.

If, by 'touchy-feely' you mean soft-skills like empathy and listening to the patient: your claim is unfounded. This is called 'bedside manner' and is part of ordinary medical practice.

If, by 'touchy-feely' you mean whatever non-medical services the patients has in mind based on their culture... sure. But the expression is that you don't go to the pigsty looking for wool. You don't go to the doctor looking for spiritual experiences. In principle, your complaint about ignoring the touchy-feely could apply to the phone company and my mechanic.

Mental health is not necessarily the same, and includes things like pain which are quite real, objective, measurable, and cost money in the form of pain medications and all the things that those medications mess up.

Having worked with NDs, Chiropractors, and non-ND herbalists, I can assure you that the last patient they want to take on are psychiatric patients, although there are exceptions.

Specifically, my ND colleage here in Vancouver explicitly denies the existence of mental illness. These patients are technically untreated under her care.

Oh, but her office has incense, so the patient is happy. When she shows up for 'treatments'. Is this what you meant by 'touchy-feely'?

Frauds exist in mainstream medicine too.

And there is definition of what this fraud looks like - treatment contrary to best medical evidence, lying to them &c - and a system created to punish them.

It sounds like your suggestion is to legalize a segment of this fraud for some reason.

Specifically, treating patients contrary to best evidence, and lying to them. Sounds like you're explicitly advocating for blatant fraud.

saizai

31st January 2009, 06:51 PM

The main argument against placebo strategies is specifically that there is little evidence that there is an effect above and beyond nontreatment. Most of the 'placebo effect' is the illness' natural course of improvement.

Please read the Cochrane Collaboration's literature review. There is very little evidence that there is any improvement that can be attributed to taking a placebo that would not take place untreated.

If this is true, then I agree it'd be a major problem.

However, it contradicts what I learned in school (CogSci, UC Berkeley), so I'd like to see proof.

Link to the review you cite?

How do you explain the "placebo opiate" study I mentioned earlier given your assertion that placebo has no effect over nontreatment? I can't find the cite right now, but could if necessary; it's a very straightforward and commonly cited example of a placebo effect.

How would you explain the study about perceived effect of caffeine differing based on whether the subject is told what they took or not? (James-Lange's work, IIRC.)

You seem to be discussing an array of subjects which you know nothing about. This is evident due to a number of contradictions in what you've said. i.e. pain is about perception, but it is objective and measurable.

I said that pain is objectively measurable. Not that pain, itself, is objective.

One such measure - of pain tolerance - is to ask a subject to put their hand in freezing water. How long they can tolerate it is an objective measure.

Another is, given a patient with self-dosing ability (which is available to many people with severe pain conditions), how much do they dose? This is an objective measure of pain control behavior, and ergo of perceived pain (once averaged out over everyone). It can certainly be used as the outcome function of a double-blind controlled trial of some other factor of treatment, to see if their pain improves.

You insist that seeing an alt therapist for mental health issues instead of a mental health specialist is not the same as seeing an alt therapist for cancer instead of an oncologist. How is it different? Both are schools of medicine. Both involve scientifically documented and peer reviewed observations, and mental health also includes one's physiology (hormonal and chemical imbalances for example).

Because at least some evidence shows that people get significant mental health benefits - perhaps equal to professional treatment - from a large number of activities. Including support groups (no PhD required), empathic friends, etc.

Just because a profession exists does not mean it is necessarily 100% better than the alternative. Mind that I'm saying that alt treatment is a secondary method, here - i.e. not that it is exactly as good as professional therapy, but that it does do significant benefit. That's a different standard than what you seem to be asserting.

For cancer, that's not the case, simply because there are only a limited number of things that effectively control cancer, and those tend to require significant resources & education to be able to administer.

Well, what about the personal preference of the person who doesn't want to see an oncologist because of the stigma of "having cancer"?

That's their choice, if they want to make it.

But as above, oncologists have evidence-backed monopoly on effective care. Psychologists do not.

As for fraud in alt therapies -- ALL alt therapies are fraudulent. 100% are. Why? Because science has shown them to fail at all their claims.

Sorry, but that's just propaganda.

Suppose a massage therapist claims that they can reduce muscle tension and relieve pain.

This is objectively supported truth in the studies I've read. Yet you'd wrap it in with e.g. ******** claims by homeopaths that they can cure AIDS.

Not all alt therapies are alike, nor are all claims alike. You're lambasting some straw man.

But you obviously don't care about that, as you're the one here advocating that doctors should lie to their patients, and undermine every step towards a trusting doctor patient relationship.

I gave two specific examples, and only two. You haven't refuted them.

Do so, and knock off the foaming at the mouth. You're arguing against some imaginary opponent, not against what I actually said.

These are the best we have, and there is a risk of reification - falsely believing that improvement in reported pain is an improvement in actual pain. But it's not ridiculous to tentatively treat them as equivalent when considering the purpose of medicine is to improve patient metrics' outcomes.

What exactly is the difference between actual and reported pain? Unless you're claiming a difference between reported and perceived, i.e. patients put on false pretenses for social effect (rather than that their perceived and "actual" pain are different)...

patient doesn't want to disappoint the doctor, so pushes through the pain, undergoing more discomfort than in baseline tests

This is routinely addressed by having the tester be a different person than the treatment administrator, and be blinded to the latter.

If the mechanism is that customer are gritting their teeth and pushing through pain just to make the physician happy, I can't understand why there's an argument that this is in any way ethical. Especially considering the lack of evidence for clinically relevant improvement.

Sure. If.

But you're implying that that "if" is in fact true of all alt therapies (or even merely more common than in standard treatment), which you've done nothing whatsoever to prove.

This sounds like an attempt to jettison the fundamental patient right of disclosure.

It's a right, sure.

But not everyone wants that right. So far nobody's given an actual direct counterargument for why one should force a patient to know something they don't want to know.

This is the core debate: is there such a situation?

Yes, according to the research I read in my university education.

If, by 'touchy-feely' you mean soft-skills like empathy and listening to the patient: your claim is unfounded. This is called 'bedside manner' and is part of ordinary medical practice.

If, by 'touchy-feely' you mean whatever non-medical services the patients has in mind based on their culture... sure. But the expression is that you don't go to the pigsty looking for wool. You don't go to the doctor looking for spiritual experiences. In principle, your complaint about ignoring the touchy-feely could apply to the phone company and my mechanic.

I mostly mean the former, though both are part of it.

But simply put: people *can* be good surgeons/oncologists/dentists/whatever while sucking at empathy &c. Not all are, sure; some manage to be both.

Why not simply have other people whose job it is to provide this service, when the primary care doctor - whose responsibility is biological outcomes - typically does not have the time nor primary responsibility for it?

Having worked with NDs, Chiropractors, and non-ND herbalists, I can assure you that the last patient they want to take on are psychiatric patients, although there are exceptions.

I'm not talking about severe cases of psychiatric illness; please don't red herring that.

I've only been referring to the normal course of patient care - pain, depression, etc related to serious illness or injury.

And there is definition of what this fraud looks like - treatment contrary to best medical evidence, lying to them &c - and a system created to punish them.

It sounds like your suggestion is to legalize a segment of this fraud for some reason.

It is not.

I gave two and only two specific examples of where lying may be justified.

I specifically said that they are not part of the treatment I've been discussing.

"Contrary to best medical evidence" is only relevant to treatment of biological conditions - and I said in the OP that that would be required to be done by mainstream medicine, explicitly because it's been proven to work and alt treatments have not.

The only domain of alt treatment as I have discussed it is pain and emotional health. Explicitly not anything to do with biological outcome.

For the sake of this argument, and to ensure that we don't have any more of this straw-man counterargument, let's say that from here on out "alt treatment" means "massage therapy with no claims whatsoever outside the scope of muscle and pain relief".

It's just one example, but at least it's distinguished from what y'all seem to keep pretending I mean.

fls

31st January 2009, 07:37 PM

Some (hopefully) useful references:

http://www.cochrane.org/reviews/en/ab003974.html

http://content.nejm.org/cgi/content/full/344/21/1594

http://www.ncbi.nlm.nih.gov/pubmed/80579?dopt=Abstract

http://www.nature.com/nature/journal/v306/n5940/abs/306264a0.html

http://cat.inist.fr/?aModele=afficheN&cpsidt=1185626

Why not simply have other people whose job it is to provide this service, when the primary care doctor - whose responsibility is biological outcomes - typically does not have the time nor primary responsibility for it?

This sounds reasonable. However, the alt. med. thing seems to be a red-herring - why bring them into it when the same thing can be accomplished with conventional medicine?

Since when is massage alt. med.?

Linda

saizai

31st January 2009, 07:48 PM

Some (hopefully) useful references:

I'm only able to access the NEJM article, and have queued it for reading later.

Any chance you could send me the full PDFs of the others? PM for email.

This sounds reasonable. However, the alt. med. thing seems to be a red-herring - why bring them into it when the same thing can be accomplished with conventional medicine?

Pure pragmatics, as above.

Conventional medicine just isn't addressing these aspects of care thoroughly or fast enough, and there are extant practitioners of alternative treatments that could address the issue at lower cost.

Cost that I think, in at least some cases, would be a net financial benefit when one considers cost of pain medicine, extended care, lost work, etc.

I have nothing whatsoever against these things being addressed within normal care, and indeed I think it'd be great if it were. It just isn't, yet. While that's the case, there's opportunity for others to fill the gap.

Since when is massage alt. med.?

Seems to be to me. But let's compromise - give a short list of what you consider to be in the category, and I'll tell you what from it I'd agree is a reasonable example for this.

fls

31st January 2009, 08:12 PM

I'm only able to access the NEJM article, and have queued it for reading later.

Any chance you could send me the full PDFs of the others? PM for email.

I don't have PDF's of the others that I can send.

Conventional medicine just isn't addressing these aspects of care thoroughly or fast enough, and there are extant practitioners of alternative treatments that could address the issue at lower cost.

I think your assumptions are unsupported. If the will and resources are available to address these aspects of care, they can just as easily be applied to extant practioners of conventional medicine. There isn't any particular reason to think that practitioners of alternative treatments can address these issues better. There isn't any particular reason to think that their costs would be lower.

I have nothing whatsoever against these things being addressed within normal care, and indeed I think it'd be great if it were. It just isn't, yet. While that's the case, there's opportunity for others to fill the gap.

What makes you think they'd be any better at filling the gap?

Seems to be to me. But let's compromise - give a short list of what you consider to be in the category, and I'll tell you what from it I'd agree is a reasonable example for this.

Homeopathy, therapeutic touch, chiropractic, herbalism...

Linda

saizai

31st January 2009, 08:27 PM

I think your assumptions are unsupported. If the will and resources are available to address these aspects of care, they can just as easily be applied to extant practioners of conventional medicine. There isn't any particular reason to think that practitioners of alternative treatments can address these issues better. There isn't any particular reason to think that their costs would be lower.

I didn't claim either - with the caveat that costs would be lower than the same thing being provided by full doctors (because their time is expensive). Of course hospitals could provide the equivalent, e.g. in the form of a large number of LCSWs.

It could be done. It just isn't.

There's no reason for me to believe that this will change trajectory, ergo I assume it won't and just fiddle with what resources are currently available.

Homeopathy, therapeutic touch, chiropractic, herbalism...

How about theraputic touch in which the practitioner makes no claims whatsoever outside of pain relief and improved mood?

Yuri Nalyssus

1st February 2009, 03:05 AM

I have nothing whatsoever against these things being addressed within normal care, and indeed I think it'd be great if it were. It just isn't, yet. While that's the case, there's opportunity for others to fill the gap.
This is pure navel gazing - you started off with a hypothetical, purely complementary form of alt med which doesn’t exist in any way, shape or form and now you’re saying these imaginary practitioners are there to fill some sort of imaginary gap.

There are some ‘ancillary’ therapies such as massage, physiotherapy, counselling and dietetics which are already doing just the sort the sort of thing that you describe to support the medical profession. The difference between these practices and true CAM is that CAM doesn’t want to be brought into the establishment fold, it’s quite happy ripping people off outside the checks and measures that ensure safety, ethics and efficacy in proper medicine. True CAM practitioners at best have lost their grip on reality or at worst are cynically defrauding people, either way they’re not going to be interested in meekly kow-towing to the scientific medical establishment. That way they can make all the bogus claims for magical cures they like and there’s no one to stop them.

You will never in a month of Sundays get reflexologists to rebrand themselves as ‘foot-masseurs’ and stop pretending to fix your liver by squeezing your big toe; you will never get homeopaths to hang up their sugar tablets and just give their patients the benefit of hours of listening and exquisitely detailed questioning - they’re too busy trying to cure AIDS and malaria just like real doctors, only, unlike real doctors, homeopaths lie to people and pretend they actually can cure AIDS and malaria.

All the honest ‘ancillary’ practitioners with a grip on reality are already doing the thing you’re talking about and all true CAM practitoners would rather chew their own arms off than accept the restrictions you are proposing.

Yuri

fls

1st February 2009, 04:40 AM

I didn't claim either - with the caveat that costs would be lower than the same thing being provided by full doctors (because their time is expensive). Of course hospitals could provide the equivalent, e.g. in the form of a large number of LCSWs.

It could be done. It just isn't.

There's no reason for me to believe that this will change trajectory, ergo I assume it won't and just fiddle with what resources are currently available.

But that's the point. These resources aren't currently available. Alt. med. practitioners aren't already on staff in hospitals. If someone is going to invest time and money into performing needs assessments and hiring new staff, why not just hire staff that you already know have the skills and training to do the job instead of a bunch of people who have not had the training, may or may not have the skills, and come with a whole lot of baggage that throws their ethics into question?

How about theraputic touch in which the practitioner makes no claims whatsoever outside of pain relief and improved mood?

I agree with Yuri. Why would alt. med. practitioners agree to pervert their raison d'etre? You'd have to hire a whole bunch more people just to police them.

Linda

Mojo

1st February 2009, 05:06 AM

I agree with Yuri. Why would alt. med. practitioners agree to pervert their raison d'etre? You'd have to hire a whole bunch more people just to police them.

We've recently had someone on the UK Skeptics forum trying to defend chiropractic on the basis that reputable chiropractors don't claim o be able to treat anything other than "spinal and joint related problems" and claimed that any chiropractors who said they could threat anything beyond this were "holistic medicine types posing as chiropractors".

Rolfe

1st February 2009, 09:21 AM

Uh, do we have to go back over the fact that therapeutic "touch" doesn't involve actual touching? Why would anyone believe that simple handwaving (literally) would relieve pain and/or improve mood if it wasn't surrounded by all that nonsense about manipulating the patient's aura?

Patients may be gullible, but most of them aren't that daft.

Rolfe.

blutoski

1st February 2009, 11:30 PM

If this is true, then I agree it'd be a major problem.

However, it contradicts what I learned in school (CogSci, UC Berkeley), so I'd like to see proof.

Link to the review you cite?

By the time I returned to the forum, FLS was kind enough to provide the links.

How do you explain the "placebo opiate" study I mentioned earlier given your assertion that placebo has no effect over nontreatment? I can't find the cite right now, but could if necessary; it's a very straightforward and commonly cited example of a placebo effect.

How would you explain the study about perceived effect of caffeine differing based on whether the subject is told what they took or not? (James-Lange's work, IIRC.)

The usual concerns apply:

1. it is up to the advocate of actual change vs merely reported change to distinguish these from reporting bias, as I described in my post above.

2. statistics - the more studies you do, the more you're going to get in falling outside the confidence interval out of pure chance (false positives in p<=.05 happen one time in twenty - how many placebo studies are there?)

3. knowing, #2, there's tremendous risk of reporting error - how many of these authors' studies were unpublished? Was this because they only publish positive results (the advocate of actual change is making the claim, and would be responsible for showing the reporting rate is not filedrawered)

4. are there any clinically relevant outcomes? or are we just talking at best that we've spent 100 years on placebo studies and still have nothing more than a proof of concept? (this is typical of phenomena that are just explanations for 'background noise' see #2)

Even the recent paper that set off a flurry of placebo crap has been reported way beyond the authors' comfort. From the conclusion (and in reference to #1 concern I listed above, bolding mine):

*Date: 2009.01.28@22:11.37 - Acupuncture treatment for pain: systematic review of randomised clinical trials with acupuncture, placebo acupuncture, and no acupuncture groups
[b]A small analgesic effect of acupuncture was found, which seems to lack clinical relevance and cannot be clearly distinguished from bias. Whether needling at acupuncture points, or at any site, reduces pain independently of the psychological impact of the treatment ritual is unclear.

URL: [Acupuncture treatment for pain: systematic review of randomised clinical trials with acupuncture, placebo acupuncture, and no acupuncture groups (http://www.bmj.com/cgi/content/full/338/jan27_2/a3115)]

I said that pain is objectively measurable. Not that pain, itself, is objective.

One such measure - of pain tolerance - is to ask a subject to put their hand in freezing water. How long they can tolerate it is an objective measure.

Another is, given a patient with self-dosing ability (which is available to many people with severe pain conditions), how much do they dose? This is an objective measure of pain control behavior, and ergo of perceived pain (once averaged out over everyone). It can certainly be used as the outcome function of a double-blind controlled trial of some other factor of treatment, to see if their pain improves.

Absolutely, but the claim that placebo-power people are making is not that treatment rituals increase these objective outcomes, but that - say, in this example - they actually relieve pain. This is unproven until we can measure pain itself objectively, without proxies.

Again: consider the senior who is trying to please the nice doctor, and simply puts on stoicism while undergoing even worse pain. An advocate would have to show me that this was not a good explanation, and it's very very suspicious that the limited number of applications to treatment ritual have exactly this type of plausible alternative mechanism.

Because at least some evidence shows that people get significant mental health benefits - perhaps equal to professional treatment - from a large number of activities. Including support groups (no PhD required), empathic friends, etc.

I think you're mixed up here. It's well understood that people who are more socially connected and physically active are happier, but it's a correlation, and does not apply to people with mental illness. I think the situation you're talking about is that it improves the mood of healthy people who do not have psychiatric problems, which means you're not talking about an alternative or adjunct to medical treatments. It's basically changing the subject of the thread.

But as above, oncologists have evidence-backed monopoly on effective care. Psychologists do not.

Psychology is not medicine, though. I think you're drifting very far from the original post's suggestion.

What exactly is the difference between actual and reported pain? Unless you're claiming a difference between reported and perceived, i.e. patients put on false pretenses for social effect (rather than that their perceived and "actual" pain are different)...

This is exactly what is proposed, yes. It's called reporting bias.

But not everyone wants that right. So far nobody's given an actual direct counterargument for why one should force a patient to know something they don't want to know.

It's not a medical question. The question of the ethics of white lies is universal, and the basis of Kantian moral philosophy.

If you want to have that debate, simply change the thread to: "Are white lies morally acceptable?" Like all ethical questions, it's debatable.

My stand on your specific scenario is that the practitioner does not actually know what the patient does or does not want to know until it has been discussed. What we would be dealing with in actual practice is that the MD will withold information he believes the patient would not want to know. Which is very different.

Yes, according to the research I read in my university education.

I appreciate that, but either the facts have changed, or you were misinformed.

I personally have had to change my mind on this subject.

Why not simply have other people whose job it is to provide this service, when the primary care doctor - whose responsibility is biological outcomes - typically does not have the time nor primary responsibility for it?

I think this is a loaded question, and the scenario is very vague. An MD has many responsibilities, as do the rest of the healthcare professionals. Again: a massage therapist who claims to be providing reduced pain is responsible for that outcome, but just like the MD, he may or may not have a warmer bedside manner. Massage therapists run assembly-line practices just like any other bad FP.

I'm not talking about severe cases of psychiatric illness; please don't red herring that.

Sometimes you are and sometimes you are not. In any case, the situation that was most troubling was that my ND colleague does not even believe in depression. I'm not sure if you call that 'severe' or not, but her approach is to tell her patients to get their **** straight and stop moping.

I've only been referring to the normal course of patient care - pain, depression, etc related to serious illness or injury.

So, you're suggesting what, exactly, for depression, that an MD would not offer?

"Contrary to best medical evidence" is only relevant to treatment of biological conditions - and I said in the OP that that would be required to be done by mainstream medicine, explicitly because it's been proven to work and alt treatments have not.

The only domain of alt treatment as I have discussed it is pain and emotional health. Explicitly not anything to do with biological outcome.

I'm struggling to understand what you mean at all.

Pain management is considered a medical issue, and pain reduction is considered a biological outcome of treatments. A good example is that aspirin seems to reduce pain, and the mechanism is a well-studied biochemical reaction. Anaesthetic is a medical technique for reducing pain when undergoing surgeries.

Psychiatry has two domains: the organic and the cognitive. Both are studied and treated within the field, and they are both considered medicine.

For the sake of this argument, and to ensure that we don't have any more of this straw-man counterargument, let's say that from here on out "alt treatment" means "massage therapy with no claims whatsoever outside the scope of muscle and pain relief".

It's just one example, but at least it's distinguished from what y'all seem to keep pretending I mean.

In our defense, your discussion has been quite scattered, and it looks a lot like you're trying to abandon the actual claim. Massage is not even remotely related to a placebo effect, since the body is clearly being affected in ways that are medically understandable. There is no reason to involve placebo effect as an explanation for why massage makes muscles feel better and may relieve pain.

Massage is not what I'd call altmed. It's a very popular ancillary therapy to whom MDs refer appropriate patients.

There's actually a recent blog on altmed's habit of labelling science-based, solid medicine, as 'altmed' for marketing purposes on sciencebasedmedicine: [Chopra and Weil and Roy, oh my! Or: The Wall Street Journal, coopted. (http://www.sciencebasedmedicine.org/?p=336)]

And this one: [When Did Diet And Exercise Become “Alternative Medicine?” (http://getbetterhealth.com/when-did-diet-and-exercise-become-alternative-medicine/2009.01.10)] (or, speaking to your earlier post: "When did joining a soccer team become complementary medicine?")

Just to give the example a contextual framework: if you told the patient that massage therapy would increase their pain (this is the part that would connect massage to your ethical question about invoking placebo effect), do you think the patient would walk away from the experience reporting more pain? If not, then you don't think massage has a meaningful placebo effect via power of suggestion. If so, then you have a new project: find some studies that show this nocebo effect.