Ethics and alternative medicine

As requested by a fellow blogger, I'm weighing in with some thoughts about "complementary and alternative medical therapies" and the ethical implications thereof. There are plenty of other good posts to read on this general subject, most recently at Pharyngula, retired doc's thoughts, Notes from Dr. RW, and In the Pipeline.

Where I start on this is that doctors are in the odd position of trying to work from scientific knowledge and at the same time trying to provide care to human beings. A patient is not a petri dish. Not only is a human being wildly more complex than most of the experimental systems scientists try to tackle in the lab (where there are, after all, lots of controls in place), but the patient generally has strong opinions about his or her own experience. Sure, these opinions are subjective, but for the person who has them, they're mighty real. (Even if the excruciating pain I feel is "all in my head", the fact that it's in my head makes it real enough to me!)

Scientists are in the business of getting data on the observable features of the systems they're studying (and also working out clever ways to observe more of the features of those systems). They use that data to work out the structure of the system, the cause-and-effect connection, ways to predict what's coming in the system given certain conditions, and maybe even ways to alter conditions to bring about different outcomes. This can be challenging even in vitro. It is a much more impressive achievement in vivo. But it's worth noting that most in vivo research projects are vastly simplified compared to what you might think of as "the real world" of organisms (e.g., studying hundreds of mice that are very similar genetically, are housed in identical conditions, fed the same Mouse Chow at the same times every day, etc.).

In other words, to the extent that physicians are applying the fruits of scientific research to the treatment of their patients, they are often trying to extend results obtained in very controlled conditions to autonomous humans "in the wild". Given that most patients probably wouldn't want to adopt the correspondingly controlled environment, that's fine. But, it means that our best prediction of the likely outcome of intervention X is less certain than it would be under the conditions of the experiments that produced the best current knowledge about intervention X. Complicating things, even under experimental conditions, there is usually a range of outcomes observed in response to a given intervention. So, even while there may be very good evidence to support the prediction that intervention X will produce an outcome somewhere in a particular range, there may not be grounds for predicting that a particular individual will have an outcome in one part of the range rather than another.

"What does all this have to do with alternative medicine?" I hear you ask.

One of the big worries about complementary and alternative therapies is that they just don't have the science to back their efficacy. Yet, the public seems to be clamoring for them. In working out just what they should do about this state of affairs, physicians probably ought to examine why the alternatives are so attractive to so many patients. At least part of this, I think, can be explained in terms of what a tough-minded scientific approach to medicine brings with it, and how this might complicate the delivery of care (not just interventions) to the patient.

A patient shows up at the doctor's office looking for care that addresses a medical issue (an injury, a disease, prevention of some future ill). The doctor gets information about the patient's condition (via examination, lab work, and talking with the patient). Ideally, a medical intervention will effectively address the issue (repair the injury, cure disease or at least manage its symptoms, change the state of affairs in such a way as to lower the likelihood of the future ill). If the intervention can address the issue without making the patient feel like crap, that's a plus. The set of effective interventions the physician has to offer are generally those that have been proven in clinical trials. Ideally, you want trials in which administering intervention X is significantly more effective than administering an appropriately similar placebo (easier when we're talking about pills than non-drug interventions) in a double-blind set up, where neither the clinician nor the patient knows who's getting the intervention and who's getting the placebo. Such trials generate the "evidence" in evidence based medicine.

At present, very few of the alternative therapies people seek out (homeopathy, herbal medicines, chiropractic, accupuncture, etc.) have been through the double-blind clinical trial. By the evidence-based physician's lights, there is just no good reason to think they will be effective.

But for the patient who is given the best interventions evidence-based medicine has to offer, with no resolution to the issue that made him seek care in the first place, an alternative therapy may feel like something to try that might help the problem. In the same way that a 95% success rate of intervention X may be of no comfort at all if you're in the 5% not helped by that intervention, you may not care a fig if the alternative you try hasn't been demonstrated to be broadly effective -- you only care if it helps you. And even if your science-minded doctor tells you that it probably won't help you, if you feel better, you feel better. Even if it's just the placebo effect, it's still an effect, and feeling better is at least part of what you're looking for.

This does not mean, however, that physicians (and the medical schools that train physicians) ought to jump headlong into the uncritical acceptance of the whole plethora of alternative therapies. While patients need care from their physicians, they also expect that there is scientific knowledge guiding that care. Instead, it seems perfectly reasonable for the medical profession to subject the alternatives to the same sorts of clinical trials undergone by mainstream medical therapies. (Many such studies have already been done.) Such testing may turn up interventions that are as effective as mainstream interventions (remember that willow bark is an ancestor of aspirin). More importantly, it may turn up interventions that are harmful, about which patients should be informed. What to do with the interventions that prove themselves neither to be demonstrably effective nor harmful? The physician ought to be clear that the best scientfic evidence doesn't give any reason to believe that the intervention will take care of the medical issue -- but that there is little reason to expect it to be harmful, either. If the patient chose to explore the alternative, probably better that this happen with the physician's knowledge than on the sly. (It's better for the doctor to know how many parameters are being tweaked at a time, especially if the patient's condition changes.)

There is lots much that could be said here -- about who should conduct the clinical trials of alternative therapies (the medical establishment or the people selling the alternative therapies), about the psychological effects of paying a lot for a therapy on perceived improvement, on that feeling of alienation one gets from getting exactly three minutes of face-time from the treating physician and how that plays into perceptions of improvement), about the suspicions one might form that physicians are biased toward the pharmaceutical companies by something beyond scientific evidence (as I type this, my gaze falls on "Floxie", a bright blue plush drop of Fluoxetine -- regifted by a physician relative, who got it from a drug company rep). But on the question of how, ethically, a physician ought to handle the issue of alternative medical interventions, I would make the following suggestions:

1. Be clear about what is known from clinical trials and what it means to the individual patient. This goes for both mainstream and alternative therapies. Being clear about what is known (desired effects and side-effects) and what is uncertain (including just how a particular patient will respond to a particular intervention) is crucial. Saying, "This will work for you" and being wrong about it undermines your credibility.
   
2. Call the patient's attention to interventions clearly demonstrated to be dangerous and/or ineffective. This is worth doing even if the patient has shown no visible interest in these interventions; patients may choose not to discuss these with their physician (in the same way they may not be completely forthcoming about how much booze they drink, or how few vegetables they eat). To the extent that risks are known, especially for interventions readily accessable in the marketplace, patients need to know, too.
   
3. Let patients know which interventions are still untested, and what their untested status means to the patient. While "We don't know what X does to people in your condition" leaves open the possibility of good outcomes, it also leaves open the possibility of bad outcomes. Patients may have different risk-taking strategies than physicians when faced with uncertainties. This doesn't necessarily mean patients are muddle-headed; they're just concerned with a different payoff (getting better vs. having firm support from evidence). The physician ought not to get paternalistic here, but instead to give the patient a clear enough explanation of what is known and what is not known that the patient can make well-informed use of his or her autonomy.
   

There are quacks aplenty looking to make a buck on snake oil. But, the physician shouldn't let anger at the quacks spill over into hostility towards or impatience with the patients who are trying to figure out their options. Being upfront about what is known, and what is uncertain, about alternative and mainstream therapies is a good way for physicians to set themselves apart from the quacks.


Technorati tags: complementary and alternative therapies, medical ethics, evidence based medicine