Comment: Response to “Tarring complementary medicine is anti-choice”

The following is a comment to an opinion piece, “Tarring complementary medicine is anti-choice” written by Kerryn Phelps in Medical Observer.  My comments were published online on 21 March 2012.

I concur with some of the statements in the comments and feel I must support my colleagues who are members of the Friends of Science in Medicine (FSM).

The categorisation of health interventions by cultural tradition, e.g., “complimentary” or “Western”, is perhaps unhelpful. A better way to group interventions is by considering efficacy, evidence, and plausibility.

Firstly, there are interventions that have both good empiric evidence for efficacy, and high scientific plausibility (e.g., aspirin for secondary prevention of cardiovascular disease). These can be considered to be the “best” interventions, insofar our confidence that they work.

In the second group, there are interventions that have good empiric evidence for efficacy, have some scientific plausibility, but the mechanism of action is not clearly known (e.g., atypical antipsychotics for bipolar I disorder). Many modern medications fall into this category. A priority of research policy should be in investigating these interventions.

A third group are interventions that have poor (or a lack of) empiric evidence for efficacy, but are highly plausible (e.g., using new oral hypoglycaemic agents to prevent macrovascular outcomes in individuals with diabetes). Again, a priority of research should be in collecting empiric evidence – we can be misled by thinking that plausible therapies will have clinically meaningful effects.

A fourth group are interventions that have poor, inconsistent, or a lack of empiric evidence for efficacy and also lack scientific plausibility (e.g., acupuncture for most conditions). It can be argued that research should take place if the treatment is popular (potential public health impact) or there are case reports of efficacy (to assess more rigorously). However, it is unclear that these sorts of therapies should be routinely RECOMMENDED.

A fifth group are interventions that have good empiric evidence for lack of efficacy, and are implausible (e.g., homoeopathy for most conditions, or antibiotics for treatment of the common cold). These intervention strategies should be abandoned.

I’ll leave it to the reader to reflect on where interventions that are typically considered “Western” or “CAM” fall into that scheme.

The problem with focussing on the labels of “CAM” or “Western” medicine is that it is easy to make fallacious arguments. Yes, not all therapies in “Western” medicine are well based in evidence – but that does not imply that empiric evidence of efficacy and scientific plausibility are not of key importance. Similarly, not all “CAM” therapies lack evidence and scientific plausibility – but that does not imply that the majority of such therapies have either.

Individual interventions need to be judged on their own merits, and the framework for assessment should be on evidence-based scientific principles. Science is not a brand – it is simply an approach with specific methods and tools that allows us to appraise and understand the empiric universe.

Phelps’ points about Vioxx, Reductil, etc., misses the true lessons from those events. These medical scandals highlight the necessity of evidence-based and scientific medicine. When individuals and health companies sell and promote health interventions, they are incentivised to exaggerate the true utility of these treatments. I agree entirely that those scandals represent failures within Medicine. Nevertheless, we should reflect that exposition of poor interventions can occur, even if late. Where is the “scandal” in the chiropractic world that vertebral subluxations do not exist? We need more science in healthcare, not less!

Phelps is correct that “choice” may be restricted. Healthcare recommendations given by medical practitioners SHOULD be restricted by biomedical ethics. Fundamentally, our suggested therapies must be guided by an empirical understanding of reality. Individual patients are free to have any and all health beliefs and this is respected by a patient-centred model of practice. However, ethical practitioners should not engage in a conspiracy of magical thinking with their patients. It is an audacious misrepresentation to suggest that members of the FSM support paternalistic doctor-patient relationships.