More Harm than Good?: The Moral Maze of Complementary and Alternative Medicine

240 Pages·2018·2.42 MB·English

by  Edzard Ernst

MOR E
HAR M
THAN
GOOD?
The Moral Maze
of Complementary and
Alternative Medicine
Edzard Ernst
Kevin Smith
More Harm than Good?
Edzard Ernst Kevin Smith
(cid:129)
More Harm than Good?
The Moral Maze of Complementary
and Alternative Medicine
123
Edzard Ernst KevinSmith
University of Exeter Schoolof Science, Engineering
Exeter andTechnology
UK Abertay University
Dundee
UK
ISBN978-3-319-69940-0 ISBN978-3-319-69941-7 (eBook)
https://doi.org/10.1007/978-3-319-69941-7
LibraryofCongressControlNumber:2017957706
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To Danielle
Edzard Ernst
To Louise, Primrose and Abigail
Kevin Smith
Preface
There are hundreds of books on complementary and alternative medicine (CAM).
Theycoverallimaginableaspectsofthesubject,yethardlyanyofthemdiscussthe
often-serious ethical problems created by the current popularity of CAM.
Why is that?
Most consumers seem to think that ethical issues are academic, bone dry,
uninterestingandnotrelevanttothem.Webelievethatthisviewisverywrong,so
much so that we have written this book which is entirely focused on the ethical
problems that arise in CAM.
Ethicalissuesinmedicineaffectallofus,andthemoreactivelythatindividuals
engage with ethical discourseanddecision-makingthebetter.However,if medical
ethics were merely an academic subject, impenetrable to nonspecialists, it would
have little practical value. Accordingly, in this book, we will refer to formal aca-
demicethicaltheoryonlywherenecessary;whereverpossible,ourdiscussionswill
be based on straightforward argumentation and will refer only occasionally to
theory. But, where appropriate, we will utilise theoretical approaches to help
analyse specific ethical issues that arise in CAM. For those unfamiliar with the
principles of medical ethics, a more in-depth introduction is provided in the
‘Introduction to Medical Ethics’ section which follows this foreword.
Inallareasofhealthcare—andCAMisnoexception—consumersareentitledto
expect certain basic ethical precepts to be satisfied. These include the following:
(cid:129) Competence: healthcare practitioners should be sufficiently skilled and knowl-
edgeable such that their clinical practice iseffective and their medical advice is
valid and up to date.
(cid:129) Evidence:profferedtreatmentsanddiagnosticproceduresshouldbebasedupon
valid knowledge, obtained through robust processes of scientific research.
(cid:129) Education:programmesofpractitionereducationandtrainingshouldensurethat
only qualified, competent practitioners are licensed to practice; these pro-
grammes should impart the ability to think critically such that evidence can be
evaluated in an impartial fashion.
vii
viii Preface
(cid:129) Autonomy: patients should be at liberty to choose whether to employ a treat-
ment,withfullinformationbeingprovidedtoexplainhowtheproposedtherapy
works, along with its risks and benefits. Additionally, if any other effective
therapeutic options exist, these should be fairly presented.
(cid:129) Honesty: CAM professionals should behave truthfully; this includes practi-
tioners, professional bodies, clinics and sellers of CAM therapies.
(cid:129) Absence of exploitation: patients, clinical trial participants and consumers
should be confident that they will not be taken advantage of or abused.
These essential elements of medical ethics are supported by all of the formal
ethical approaches and principles outlined in the next section. As we shall explore
in this book, these basic ethical requirements are frequently neglected, ignored or
wilfully violated in CAM. We feel it is important to disclose these problems and
discussthemcritically.Onlythencanwehopetomakeprogressandhopetoserve
the best interests of patients and consumers.
Exeter, UK Edzard Ernst
Dundee, UK Kevin Smith
Acknowledgements
WeoweadebtofgratitudetoProf.DavidColquhounforhisgeneroushelpwiththe
statistical aspects of this book.
ix
Contents
Introduction to Medical Ethics..... .... .... .... .... .... ..... .... xvii
1 Clinical Competence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1 What Does ‘Competent’ Mean?. . . . . . . . . . . . . . . . . . . . . . . . . . . 2
2 Competence and Plausibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
3 Competence and Evidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
4 A Homeopath’s Advice on the Treatment of Diabetes . . . . . . . . . . 7
4.1 The Story . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
4.2 Plausibility and Evidence. . . . . . . . . . . . . . . . . . . . . . . . . . . 8
5 Incompetent Advice on Vaccination . . . . . . . . . . . . . . . . . . . . . . . 8
5.1 The Story . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
5.2 Plausibility, Evidence and Ethics . . . . . . . . . . . . . . . . . . . . . 9
5.3 Ethics and Vaccination . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
6 Incompetence of CAM Organisations . . . . . . . . . . . . . . . . . . . . . . 15
6.1 The Story . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
6.2 Plausibility and Evidence. . . . . . . . . . . . . . . . . . . . . . . . . . . 15
7 Incompetent Charities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
7.1 The Story . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
7.2 Plausibility and Evidence. . . . . . . . . . . . . . . . . . . . . . . . . . . 18
8 True Cases. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
9 Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
2 Research Fundamentals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
1 Good and Bad Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
1.1 Nonhuman Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
1.2 Anecdotal Evidence. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
1.3 Experimental Versus Observational Studies. . . . . . . . . . . . . . 32
1.4 Randomised Clinical Trials (RCTs) . . . . . . . . . . . . . . . . . . . 35
2 Data Analysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
xi
xii Contents
2.1 Endpoints . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
2.2 P-Value Pitfalls. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
2.3 Statistical Power . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
2.4 Prior Probability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
2.5 Statistics: Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
3 Systematic Reviews . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
4 Research Activity: Mainstream Versus CAM . . . . . . . . . . . . . . . . . 53
5 Problems with CAM Research . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
6 Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
3 The Reality of CAM Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
1 Problems with Controls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
1.1 No Control Group: Reiki and Stress Management . . . . . . . . . 61
1.2 No Control Group: Homeopathy and Diabetes . . . . . . . . . . . 63
1.3 No Control Group: Herbal Medicine
and Sleep Quality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
1.4 No Control Group: CAM Medication for Cancer Hormone
Therapy Side-Effects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
1.5 Lack of an Adequate Control Group: Chiropractic
and Acupressure for Headaches . . . . . . . . . . . . . . . . . . . . . . 67
1.6 No Placebo Control Group: Aromatherapy,
Reflexology and Rheumatoid Arthritis . . . . . . . . . . . . . . . . . 68
1.7 No Placebo Control Group: CBT, Reiki
and Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
1.8 Pseudo-control Group: CAM and Cancer
Chemotherapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
1.9 Pseudo-control Group: Homeopathy and Respiratory Tract
Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
2 ‘A + B Versus B’ Trials. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
2.1 ‘A + B Versus B’ Design: Manipulation, Exercise
and Leg Pain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
2.2 ‘A + B Versus B’ Design: Acupuncture
and Hot Flashes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
2.3 ‘A + B Versus B’ Design: Mindfulness,
CRT and Back Pain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
3 Problems with Results from CAM Studies. . . . . . . . . . . . . . . . . . . 77
3.1 Secondary Endpoints: Craniosacral Therapy
and Back Pain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
3.2 Statistical Malpractice: Homeopathy
and Postoperative Recovery . . . . . . . . . . . . . . . . . . . . . . . . . 78
3.3 Too Good to Be True? Bach Flower Remedies
and Carpal Tunnel Syndrome. . . . . . . . . . . . . . . . . . . . . . . . 79
3.4 Too Good to Be True? Wet Cupping and Back Pain. . . . . . . 80