It is hard to claim pure motives when suggesting that patients try untested therapies.
Fam Pract Manag. 2005 Apr;12(4):13-14.
I recently participated in a seminar about nontraditional treatments for common medical disorders. I listened as allopathic and osteopathic family physicians described offering their patients alternative remedies like herbs, acupuncture, acupressure and hypnotherapy and modalities like electromagnetic stimulation. I have many patients who have interest in nontraditional treatments, and I hoped to learn enough to teach myself and my patients more. After three hours, though, I emerged with some troubling questions about the role of physicians in alternative medicine.
Several concepts kept coming up in the presentation. Our discussion leaders told us that their interest in alternative medicine had been motivated like mine – by patients who began inquiring about herbs or magnets. Most of the physicians had been encouraged to learn more by their institutions. One physician had even been asked to lead a new Alternative Therapies Center. “Many patients really want these therapies and are willing to pay for them,” he told me after the session. “Consider the cash flow that a little bit of acupuncture can generate. In this country the business of alternative medicine is clearly booming.”
But my sense of unease grew during the lectures. Again and again, my colleagues led with a disclaimer that there was no proof in the medical literature supporting the use of their techniques. Herbs had untested interactions and unmonitored purities, they pointed out. Empowered and calm patients seemed to do better, though the presenters allowed that no studies have examined the effects of meditation. They mentioned that acupressure and acupuncture are supported by a wealth of anecdotal evidence spanning thousands of years but admitted that they have not been proven with modern methodologies.
The presenters did a great job applying scientific principles to an unscientific topic. There was little scientific literature to rely on, but they reassured us that while alternative medicine approaches might not yet be proven to help, they would almost certainly not hurt our patients. Yet there was still something very troubling to me about our discussions.
I recalled conversations during an ethics class in medical school about the use of placebos. One day I asked my professor, “What is wrong with using a placebo if you think it will give the patient relief?” He patiently explained principles of autonomy and honesty to me, telling me what I should have intuited: lying to patients is never justified. Even if the patient feels relief from a sham treatment, it cannot possibly outweigh the damage a physician does to his patients’ autonomy and trust. “You can never go wrong by being honest with your patients,” my professor said. “Tell them what you know to be true. Your role is to advise them about the uses of medical science. When we give them full information, our patients can make good decisions for themselves.”
Maybe advocating an unproven alternative approach was like giving a patient a placebo. After all, both are likely harmless, and both might help give the patient relief. But it seemed to me that the topic of alternative medicine was even more complicated. A physician might prescribe a placebo because it could provide a patient relief without physically endangering him or her. In that case the primary motivation is selfless, in hoping to help without harming. But none of us could legitimately claim pure motives where alternative treatments are concerned.
When we offer alternative treatments, we advise our patients, treat them and then cash their checks. We respond to a demand in the marketplace, hoping to help patients and then profit from it. We might help our patients, but there is no proven benefit to the treatment we offer. We assume we will not hurt them, but the safety of what we do is not really proven to today’s randomized, controlled standards, either. Aren’t we more like snake oil salesmen when we pitch alternative medicine to our patients?
To be sure, we all have much to gain by embracing change in medicine. Other cultures and non-Western medical traditions have much to teach those of us who are open-minded enough to listen. The list of “traditional” medical advances that have grown out of “alternative” avenues is long and important. In this environment, it is more crucial than ever not to lose sight of our responsibilities. Patients come to us for help in filtering. They trust that our traditions of integrity and scientific inquiry will help us to help them navigate a bewildering array of health care offerings. They could go to an herbalist or an acupuncturist or a massage therapist for alternative treatments alone. Instead, some of them visit us for a “scientific” seal of approval.
We must respond to our patients’ trust with integrity. Let’s do more soul-searching before we advise patients about untested therapies. Let’s make sure we are not administering acupuncture needles or gingko to patients just because of market demands. We must insist that clinical trials test alternative approaches before we embrace them. We would not place our patients on methotrexate before learning that it was safe and effective. Let’s not give them magnetic treatments without the same standard. That’s not “alternative medicine,” or even “traditional medicine”; it’s just good medicine.
WHAT DO YOU THINK?
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