complementary and alternative medicine: science, pseudoscience, and ethics

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Complementary and Alternative Medicine: Science, Pseudoscience, and Ethics. Martin Donohoe, MD, FACP Karen Adams, MD, FACOG. Outline. What is CAM? Philosophies of CAM and Western medicine Recognizing Quackery, Pseudoscience and Bogus Discoveries Risks and Benefits of Herbal Remedies - PowerPoint PPT Presentation

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  • Complementary and Alternative Medicine:Science, Pseudoscience, and EthicsMartin Donohoe, MD, FACPKaren Adams, MD, FACOG

  • OutlineWhat is CAM?Philosophies of CAM and Western medicineRecognizing Quackery, Pseudoscience and Bogus DiscoveriesRisks and Benefits of Herbal RemediesWhy Herbs are Not RegulatedConclusions and Recommendations

  • What is CAM?Any health care intervention not offered by traditional Western physiciansE.g., chiropractic, massage, acupuncture, homeopathy, distance healing, therapeutic touch, Reiki therapy, aromatherapy, herbs/nutraceuticals

  • CAMSome are recommended by physicians for certain conditions or people:Chiropractic, massage, acupuncture, aromatherapyProven benefit e.g., acupuncture for certain types of chronic pain, chemotherapy-induced nausea and vomiting; guided imagery to reduce stress of surgery in children and adults

  • No Such Thing as CAMGood medicineScientificEvidence-BasedQuality ControlPeer ReviewedHumanistic and Caring

  • No Such Thing as CAMBad MedicineNon-scientificPoor or No Quality ControlNon-Peer ReviewedImpersonal, Uncaring

  • CAM is Not Unique in Its Emphasis on:Humanistic health careEmpathy and CompassionEmphasis on healing the mind and body / recognizing the powerful links between the two

  • CAM is Not Unique in Its Emphasis on:Care involving family, friends, religious practitionersCare emphasizing the whole patient or the provider-patient relationship

  • CAM Versus Western MedicineThese attributes are the characteristics of quality medicine and public health, yet have been co-opted by the CAM movement

  • Dont get sCAMmed by CAMSome CAM is without benefit, some harmfulTherefore, it is important to be able to recognize quackery, pseudoscience and bogus discoveries

  • How Quackery HarmsEconomic harm individual costsDirect harmMedical e.g., cyanide toxicity from laetrile, electrolyte imbalances from coffee enemas, quadriplegia from cervical spine manipulationsPsychological e.g., unjustified guilt, distortion of perspective

  • How Quackery HarmsIndirect harm:E.g., delay in seeking careHarm to Society:Perpetuates pseudoscience, puts other contemporary and future patients at risk

  • Warning Signs of a Bogus Scientific DiscoveryThe discoverer pitches the claim directly to the mediaThe discoverer says that a powerful establishment is trying to suppress his/her workThe scientific effect involved is always at the very limit of detectionEvidence for a discovery is anecdotal

  • Warning Signs of a Bogus Scientific DiscoveryThe discoverer says a belief is credible because it has endured for centuriesThe discoverer has worked in isolationThe discoverer must propose new laws of nature to explain an observation

  • Characteristics of PseudoscienceIndifferent to factsLooks only for evidence supporting hypothesisIndifferent to criteria of valid evidenceRelies heavily on subjective validationDepends on arbitrary conventions of human culture, rather than on unchanging regularities of nature

  • Characteristics of PseudoscienceAvoids putting its claims to meaningful testsOften contradictoryDeliberately creates mystery where none exists, sometimes by omitting important detailsDoes not progressAttempts to persuade with rhetoric, propaganda and misrepresentation

  • Characteristics of PseudoscienceAppeals to false authority, emotion, sentiment, or distrust of established factsExtraordinary claims and fantastic theoriesOften described by an invented vocabulary of words with ambiguous meaningsRelies on anachronistic thinkingAppeals to vanity, fear, magical thinking or desperation

  • Characteristics of PseudoscienceRelies on anecdotes and testimonialsProducts often claim to be effective against a wide range of unrelated diseasesQuick, dramatic results promised for one-time therapies; frequent re-treatments/maintenance treatments required for ongoing therapies$

  • Characteristics of PseudoscienceDisclaimers couched in pseudo-medical jargonClaims that Western Medicine is dangerousPractitioners advise, Dont trust your doctor

  • Characteristics of PseudoscienceClaims of no side effectsProducts claimed to be natural usually are not

  • Misconceptions re Cancer

    Cause

    Anglos

    Latinos

    Sugar Substitutes

    42%

    58%

    Bruises from trauma

    34%

    53%

    Microwaves Ovens

    23%

    47%

    Eating Pork

    11%

    31%

    Eating Spicy Food

    8%

    15%

    Breast Feeding

    6%

    14%

    Antibiotics

    12%

    32%

  • Misconceptions re Cancer

    Anglos

    Latinos (fatalismo)

    Death Sentence

    26%

    46%

    Gods Punishment

    2%

    7%

    Largely Unpreventable

    18%

    26%

    Uncomfortable to touch CA pt.

    8%

    13%

    Perez-Stable.JAMA 1992;268:3219-3223.

  • Ban Dihydrogen Monoxide?Iowa junior high school student science fair project100 adults surveyed at State Fair

  • Would you sign a petition to ban dihydrogen monoxide?1. It can cause excessive sweating and vomiting 2. It is a major component in acid rain 3. It can cause severe burns in its gaseous state 4. It can kill you if accidentally inhaled 5. It contributes to erosion 6. It decreases effectiveness of automobile brakes 7. It has been found in tumors of terminal cancer patients

  • Ban Dihydrogen Monoxide?Results90 yes8 Get away from me kid! I dont sign petitions.2 Are you kidding - that is water!

  • One Reason Why Pseudoscientific Beliefs are Common: Public Education is in DisarrayU.S. Schools ranked lowest among western nations, particularly in science funding, infrastructure decaying1/4 of U.S. Schools have no library1/4 of schools use textbooks from the 1980s or earlier

  • Geographic IgnorancePercent of US teens unable to locate the following on a map:United States 11%Pacific Ocean 29%Japan 58%United Kingdom 68%

  • Pseudoscientific BeliefsPercentage of Americans who believe at least to some degree in these phenomena

    19761997Astrology17% 37%UFOs24% 30%Reincarnation 9% 25%Fortune-Telling 4%14%

  • Ignorance/Pseudoscientific BeliefsHalf of US citizens do not believe in evolution and do believe that humans and dinosaurs coexisted (2007)40% think scientists still generally disagree about evolution

  • Pseudoscientific Beliefs37% believe places can be haunted (2007)25% believe in UFOs (2007)24% believe in astrology (2009)16% believe that people with the evil eye can cast curses or harmful spells14% have consulted a psychic or fortune teller (2009)

  • Ignorance/Pseudoscientific Beliefs22% of Americans dont know whether an atomic bomb has ever been dropped (2000)20% of Americans dont know the earth revolves around the sun (1999)18% believe in Bigfoot and the Loch Ness Monster (2007)8% of men / 18% of women believe in astrology and fortune tellers (2007)

  • Herbal Remedies$17.8 billion on herbs and supplements in 2001$58 billion on pharmaceuticals

    12% use herbs in one year (vs. 2.5% in 1990)

    E.g., between 1996 and 1998, 8% of normal-weight women and 28% of obese women used non-prescription weight loss products

  • Herbal Remedies - DisclaimerMore than of current prescription and OTC medications come from plant productsMany herbs, in pure form, may be beneficialStudies poor, no incentives for industry to rigorously investigate

    Less than 0.5% of the worlds vanishing tropical plant species have been investigated for their medicinal qualities

  • What is All Natural?

    Natural means eating a balanced diet, favoring organic, local foods, and protecting the environment

  • Gauging Risks Of Herbal RemediesFDA: Manufacturer may claim that the product affects the structure or function of the body, as long as there is no claim of effectiveness for the prevention or treatment of a specific disease, and provided there is a disclaimer informing the user that the FDA has not evaluated the agentsMultiple violations / near violations

  • Why Herbs Are Not Regulated By The FDA1974: (Senator William Golden Fleece Award) Proxmire Amendment: -Nutritional supplements are not drugs

  • Why Herbs Are Not Regulated By The FDA1994: Dietary Supplement Health and Education Act -supplements excluded from purity, composition, effectiveness and safety review-supported by Orrin Hatch (R-Utah), recipient of $169,000 from pharm and nutraceutical ind. in 2000, more than any other Senator; Utah home to more herbal/nutraceutical companies than any other stateEstablished Office of Dietary Supplements

  • FDA Oversight2100 scientists in 40 labs

    1100 investigators and inspectorsMonitor and inspect 95,000 businessesVisit >15,000 facilities per yearCollect 80,000 domestic and imported product samples for label checks

  • Risks of Herbal RemediesProducts unregulated/untested Variablecollectionprocessingstoragenamingpurity

  • Risks of Herbal RemediesAdulterants and contaminants include:Botanicals e.g., digitalis, belladonnaMicroorganisms Staph aureus, E coli, Salmonella, Shigella, PseudomonasMicrobial toxins aflatoxins, bacterial endotoxinsPesticides

  • Risks of Herbal RemediesAdulterants and contaminants include:Fumigation agentsToxic metals lead, cadmium, mercury, arsenicDrugs analgesics and anti-inflammatories, corticosteroids, benzodiazepines, warfarin, fenfluramine, sildenafil1998: 32% of Asian patent medicines sold in the US contained undeclared pharmaceuticals or heavy metals

  • Risks of Herbal And Naturopathic RemediesEst. less than 1% of adverse reactions reported to FDA (vs. 10% est. for prescripti

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